Immunologic basis for development of keratoconjunctivitis sicca in systemic autoimmune diseases: Role of innate immune sensors

The literature is filled with citations reporting an increased incidence of chronic dry eye disease, also known as keratoconjunctivitis sicca, in patients with systemic autoimmune diseases such as rheumatoid arthritis, Sjögren's Syndrome, systemic sclerosis and lupus. As the most environmentally exposed mucosal surface of the body, the conjunctiva constantly responds to environmental challenges which are typically self limited, but when persistent and unresolved may provoke pathogenic innate and adaptive immune reactions. Our understanding of the pathophysiological mechanisms by which systemic autoimmune diseases cause dry eye inducing ocular surface inflammation continues to evolve. Conjunctival immune tone responds to self or foreign danger signals (including desiccating stress) on the ocular surface with an initial non-specific innate inflammatory response. If unchecked, this can lead to activation of dendritic cells that present antigen and prime T and B cells resulting in an adaptive immune reaction. These reactions generally resolve, but dysfunctional, hyper-responsive immune cells found in systemic autoimmune diseases that are recruited to the ocular surface can amplify inflammatory stress responses in the ocular surface and glandular tissues and result in autoimmune reactions that disrupt tear stability and lead to chronic dry eye disease. We here propose that unique features of the ocular surface immune system and the impact of systemic immune dysregulation in autoimmune diseases, can predispose to development of dry eye disease, and exacerbate severity of existing dry eye.

Sjögren's syndrome

Sjögren's syndrome (SS) is characterised as keratoconjunctivitis sicca (dry eyes), xerostomia (dry mouth) commonly associated with salivary gland enlargement, and is referred to as Primary Sjögren's syndrome. It is known as Secondary Sjögren's syndrome when it occurs in patients, with connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, polyarthritis nodosa, polymyositis, and systemic sclerosis. SS has also been associated with chronic graft-versus-host disease after allogeneic bone marrow transplantation, human immunodeficiency syndrome (AIDS), hepatitis C infection (HCV), chronic biliary cirrhosis, neoplastic and myeloplastic syndromes, fibromyalgia, and chronic fatigue syndrome.

Real-world treatment patterns of OTX-101 ophthalmic solution, cyclosporine ophthalmic emulsion, and lifitegrast ophthalmic solution in patients with dry eye disease: a retrospective analysis

BACKGROUND

Dry eye disease (DED) is a disorder characterized by loss of tear film homeostasis that causes ocular surface inflammation and damage. The incidence of DED increases with age. Cyclosporine ophthalmic solution 0.09% (CEQUA®; OTX-101), cyclosporine ophthalmic emulsion 0.05% (Restasis®; CsA), and lifitegrast ophthalmic solution 5% (Xiidra®; LFT) are anti-inflammatory agents indicated for DED. This analysis compared treatment patterns in patients with DED receiving OTX-101, CsA, or LFT.

METHODS

This real-world, retrospective, longitudinal cohort study utilized Symphony Health Integrated Dataverse claims from July 2019 to June 2021. The dataset included all patients with OTX-101 claims and patients with CsA or LFT claims randomly selected 2:1 to OTX-101. Patients were sorted into 3 cohorts based on index treatment. Index date was that of first treatment claim, and follow-up period was from index date to end of clinical activity or data availability. Time to treatment discontinuation (TTD), probability of discontinuation, and treatment persistence were assessed for OTX-101 vs. CsA, then OTX-101 vs. LFT. Subgroup analysis was performed based on age and prior DED treatment. Kaplan-Meier analysis and log-rank test were used to examine TTD. A logistic model evaluated association between index treatment and discontinuation. Unadjusted and adjusted odds ratios, 95% confidence intervals, and P-values were reported, with statistically significant associations based on P-values < 0.05.

RESULTS

Overall, 7102 patients (OTX-101 n = 1846; CsA n = 2248; LFT n = 3008) were eligible. Median TTD was 354 days for patients receiving OTX-101 vs. 241 days for CsA and 269 days for LFT. Log-rank test indicated TTD was significantly longer for patients on OTX-101 vs. CsA (P = 0.033). Patients on CsA were 35% more likely to discontinue treatment than patients on OTX-101; OTX-101 and LFT groups had similar discontinuation rates. After 360 days, 49.8% of patients receiving OTX-101 remained on treatment vs. 39.4% of patients on CsA (P = 0.036) and 44.0% of patients on LFT (P = 0.854).

CONCLUSIONS

Patients receiving OTX-101 remained on treatment significantly longer and were significantly less likely to discontinue treatment than patients on CsA. Older patients remained on OTX-101 significantly longer than CsA. These findings highlight treatment pattern differences in patients with DED receiving these anti-inflammatory agents.

Inflammatory bowel disease and the associated risk of dry eye and ocular surface injury: a nationwide matched cohort study

BACKGROUND

Inflammatory bowel disease (IBD) is associated with lacrimal gland dysfunction and ocular inflammation. The objective of this research was to elucidate the temporal relationships between IBD, dry eye disease (DED), and corneal surface damage.

METHODS

In a matched nationwide cohort study, we evaluated the risk of DED and corneal surface damage associated with IBD. Multivariable Cox proportional hazards regression analyses were implemented to estimate the risk of ocular complications.

RESULTS

A total of 54,293 matched pairs were included for analyses. The median follow-up time was 8.3 years (interquartile range: 5.5 - 10.5). The period incidence of DED was 8.18 and 5.42 per 1000 person-years in the IBD and non-IBD groups, respectively. After adjusting for confounders, statistically significant associations were found between IBD and DED [adjusted hazard ratio (aHR): 1.43, 95% confidence interval (CI): 1.35 - 1.51, p < 0.0001], Sjögren's syndrome-related (aHR: 1.67, 95% CI:1.46 - 1.90, p < 0.0001) and non-Sjögren's syndrome-related subtypes (aHR: 1.38, 95% CI: 1.30 - 1.46, p < 0.0001). Furthermore, increased risks of corneal surface damage (aHR: 1.13, 95% CI: 1.03 - 1.24, p = 0.0094) among the patients with IBD were observed when compared with the controls. Other independent factors associated with corneal surface damage were age (aHR: 1.003), sex (male vs. female, aHR: 0.85), and monthly insurance premium (501-800 vs. 0-500 U.S. dollars, aHR: 1.45; ≥ 801 vs. 0-500 U.S. dollars, aHR: 1.32).

CONCLUSIONS

Our results suggested that IBD was an independent risk factor for DED and ocular surface damage. Clinical strategies are needed to prevent visual impairment or losses in these susceptible patients.

Advances and prospects of platelet-rich plasma therapy in veterinary ophthalmology

In the recent decades, there has been a significant uptick on the use of platelet-rich plasma (PRP) as a better alternative for ophthalmologic therapies in pathologies, primarily of the ocular surface. PRP is a class of liquid platelet concentrate containing a supra-physiological concentration of platelets in a relatively small amount of plasma. Its potential to heal various tissues has piqued interest in its therapeutic application as a biomaterial in regenerative medicine. It is currently a popular therapeutic agent in plastic surgery, cardiothoracic surgery, reconstructive surgery, and even oral and maxillofacial surgery. Based on the data from in vitro and in vivo studies, it can be concluded that PRP possesses adequate therapeutic potential in ocular pathologies, especially those involving cornea. In addition, the high concentrations of growth factors (TGF-β, VEGF, EGF) present in the PRP accelerate the healing of the corneal epithelium. PRP has great therapeutic prospects in veterinary ophthalmology as a regenerative therapeutic modality. However, several variables are yet to be defined and standardized that can directly affect the efficacy of PRP application in different ophthalmic conditions. There is a shortage of research on the use of PRP in ocular surface defects compared to the number of studies and reports on the use of autologous and allogeneic serum eye drops. Therefore, a data-driven approach is required to generate consensus/guidelines for the preparation, characterization, and therapeutic use of PRP in veterinary ophthalmology. This review aims to inform readers of the latest research on PRP, including its preparation methods, physiological and biochemical properties, clinical applications in veterinary ophthalmology, and their safety and efficacy.

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist

PURPOSE OF REVIEW

Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease.

RECENT FINDINGS

The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

Optimal acupuncture protocol improving symptoms of typical dry eye syndrome: meta-analysis and systematic review

Previous meta-analyses have shown a superiority of acupuncture over artificial tear for treating typical dry eye syndrome (DES). However, given that the acupuncture protocols were quite diverse in the randomized controlled trials (RCTs) included in the meta-analyses, it is necessary to establish the acupuncture guidelines. Thus, the optimal acupuncture protocol involved in improvements of tear-film breakup time (BUT) or Schirmer tear test (STT) was examined by meta-analyses for RCTs in patients with typical DES. Eight databases until Jun 2018 were searched for 21 RCTs (n = 1542 eyes) comparing effectiveness of acupuncture versus artificial tear control. Indirect comparison of Bucher analysis was used to find specific acupoints (SAPs) improving BUT or STT by comparing the outcomes between subgroups of the RCTs including and excluding certain SAPs. Meta-analysis was examined for the outcomes in subgroups of the RCTs based on the number of SAPs, and network meta-analysis was for multiple pairwise comparisons across the protocols using the SAPs to yield relative effects. The Bucher analyses identified nine SAPs with positive effects on BUT or STT, and the positive relations of two SAPs involved in improvements of both BUT and STT suggested potential combinations of three ('KI3-LI4-SP6' or 'KI3-GB14-ST2') or four SAPs ('KI3-BL1-EX-HN7-SP6'). Subgroup meta-analyses showed the SAP-depending improvements of BUT or STT in the subgroups including more than three SAPs, compared with the artificial tear control. Meta-regression and network meta-analyses revealed significant correlations between the number of SAPs and the improvements of BUT and STT, and demonstrated that acupuncture using four SAPs for 21-30 days, particularly at two-three times per week, can be optimal for improving the symptoms of typical DES. These results provide useful information for guiding acupuncture in clinical trials for DES.

Precorneal retention time of ocular lubricants measured with fluorophotometry in healthy dogs

OBJECTIVE

Determine the precorneal retention time of five different ocular lubricants commonly used in dogs.

ANIMALS STUDIED

Six healthy Beagle dogs (n = 12 eyes).

PROCEDURES

Five ocular lubricants were studied: Artificial Tears Solution® (1.4% polyvinyl alcohol), I-Drop® Vet Plus (0.25% hyaluronate), Optixcare® Eye Lube Plus (0.25% hyaluronate), Systane® Ultra (0.4% polyethylene glycol 400 and 0.3% propylene glycol), and Artificial Tears Ointment® (mineral oil/white petrolatum). Each lubricant was mixed with 10% sodium fluorescein to achieve 1% fluorescein formulations. Following topical administration of 35 mg in each eye, tear fluid was collected with capillary tubes at selected times (0, 1, 5, 10, 20, 30, 40, 50, 60, 90, 120, 180 min) and fluorescein concentrations were measured with a computerized scanning ocular fluorophotometer.

RESULTS

Tear fluorescence was significantly greater with Artificial Tears Ointment® compared with other lubricant formulations from 1 to 20 min post-administration. Median (range) precorneal retention times were significantly different among the 5 lubricants, ranging from 40 minutes (20-90 min) for Artificial Tears Ointment®, 35 min (20-90 min) for Systane® Ultra, 30 min (10-60 min) for I-Drop® Vet Plus, 25 min (10-60 min) for Optixcare® Eye Lube Plus, and 10 min (10-20 min) for Artificial Tears Solution®. Precorneal retention time was significantly lower for Artificial Tears Solution® compared with the other 4 formulations.

CONCLUSIONS

This study established normative data for the retention time of common lubricants on the ocular surface of dogs, which may be used to guide clinicians with their choice of lubricant and frequency of administration.

Ocular Chronic Graft-versus-Host Disease and Its Relation to Other Organ Manifestations and Outcomes after Allogeneic Hematopoietic Cell Transplantation

Ocular chronic graft-versus-host disease (cGVHD) has been shown to significantly reduce quality of life after allogeneic hematopoietic stem cell transplantation (HSCT). To learn more about this bothersome complication, we investigated the relationship between ocular cGVHD and cGVHD in other organs. We also investigated the associations between ocular cGVHD and overall mortality, nonrelapse mortality, and relapse. In this single-center study, we retrospectively included 1221 consecutive adults who underwent allogeneic HSCT. Patients were examined by an ophthalmologist before HSCT and annually for 5 years after HSCT or more frequently if needed. Patients with dry eye disease before HSCT were excluded. The International Chronic Ocular GVHD Consensus Group criteria were used to diagnose ocular cGVHD. Nonocular cGVHD was diagnosed using the National Institute of Health criteria. Out of 601 patients who were diagnosed with systemic cGVHD during follow-up, 279 (46%) developed ocular cGVHD. Ocular cGVHD was more frequent in patients with extensive cGVHD compared to those with limited cGVHD (50% versus 29%; P < .0001) and was associated with cGVHD in skin (P < .0001), oral cavity (P = .0024), genitals (P = .0023), and nails (P = .031). The frequency of ocular cGVHD was higher in patients with skin cGVHD with sclerosis compared to those with skin cGVHD without sclerosis (70% versus 49%; P = .0003). In an adjusted time-dependent Cox model, ocular cGVHD was associated with increased nonrelapse mortality (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.17 to 2.21; P = .003), whereas there was no support for an association with relapse (adjusted HR, .85; 95% CI, .53 to 1.36; P = .5). Special attention to eye problems after HSCT should be given to patients with extensive cGVHD and cGVHD in ectodermal-derived organs (skin, mouth, nails, and genitals). Furthermore, ocular cGVHD is a potential risk factor for nonrelapse mortality. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Updates in diagnostics, treatments, and correlations between oral and ocular manifestations of Sjogren's syndrome

Sjogren's syndrome (SS) is characterized as an autoimmune disorder targeting secretory glands, including the lacrimal and salivary glands, causing dry eye and dry mouth predominantly in women over the age of 40. In this review, we summarize recent advancements in SS diagnostics, treatments, and our understanding of correlations between oral and ocular manifestations of SS. Google Scholar and PubMed databases were utilized to search peer-reviewed papers since 2016 on SS diagnosis, treatment, and correlations between oral and ocular manifestations. For diagnostics, we discuss the updated SS classification criteria by the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR), new biomarkers, and compare studies of current diagnostic methods with alternative technologies. For treatments, we discuss topical, systemic, and surgical treatment developments in the management of oral and ocular symptoms of SS as there is still no cure for the disorder. Finally, we report studies that directly suggest correlations between the ocular surface disease and oral disease in SS, as well as shared abnormalities in the microbiome and cytokine expression that may be correlated. We conclude by stating limitations to our review as well as paths moving forward. Elucidating correlations between oral and ocular manifestations may be the key to furthering our understanding of SS pathogenesis as well as defining new standards for diagnosis and treatment.

Placebo administration for dry eye disease: a level I evidence based systematic review and meta-analysis

Background

The efficacy of various common treatment options for dry eye disease (DED) has been investigated against placebo. However, the potential beneficial effect of placebo in the management of DED is still unclear.

Aim

This meta-analysis investigated the impact of placebo administration in DED in Ocular Surface Disease Index (OSDI), Schirmer I test (SIT), tear breakup time (TBUT), corneal staining, and complications.

Method

This meta-analysis and systematic review was conducted according to the 2020 PRISMA guidelines. In March 2022, Pubmed, Web of Science, Google Scholar, and Embase were accessed. All the randomised clinical trials which investigated any active treatment against a placebo control group were considered. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), corneal staining.

Results

Data from 56 studies (12,205 patients) were retrieved. Placebo administration is not effective in improving TBUT (P = 0.3), OSDI (P = 0.2), SIT (P = 0.1) and corneal staining (P = 0.1) from baseline to last follow-up. Active treatment led to a higher TBUT and SIT compared to placebo administration (P < 0.0001). The active treatment resulted in a lower OSDI compared to placebo administration (P = 0.0005). Five studies reported data on the corneal staining. No difference was found between placebo administration and active treatment (P = 0.8).

Conclusion

Placebo administration does not impact symptoms of DED and can be successfully employed to evaluate the efficacy of active treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01439-y.

Selective Pharmacologic Therapies for Dry Eye Disease Treatment: Efficacy, Tolerability, and Safety Data Review from Preclinical Studies and Pivotal Trials

Keratoconjunctivitis sicca, also known as dry eye disease (DED), is a prevalent, multifactorial disease associated with compromised ocular lubrication, ocular surface inflammation and damage, and ocular symptoms. Several anti-inflammatory, topical ophthalmic therapies are available to treat clinical signs and symptoms of DED in the USA and Europe. Cyclosporine A (CsA)-based formulations include an ophthalmic emulsion of 0.05% CsA (CsA 0.05%), a cationic emulsion (CE) of CsA 0.1% (CsA CE), and an aqueous nanomicellar formulation of 0.09% CsA (OTX-101). Lifitegrast is a 5% ophthalmic solution of a lymphocyte function-associated antigen 1 antagonist that is believed to target T cell activation and recruitment to inhibit ocular inflammation. Here we provide a comprehensive review summarising preclinical studies and pivotal trial data for these treatments to provide a complete understanding of their efficacy and safety profile. Overall, data in the evaluated studies show a favourable risk-benefit profile for the use of targeted topical anti-inflammatory pharmacologic treatments in patients with DED. Pivotal trials for CsA 0.05%, CsA CE, OTX-101, and lifitegrast clearly demonstrate treatment efficacy compared to vehicle across treatments with no serious ocular treatment-emergent adverse events (TEAEs). Patients using ophthalmic treatments reported ocular TEAEs more frequently than those treated with vehicle; however, relatively few TEAEs led to treatment discontinuation. The specific signs and symptoms of DED that improve with treatment vary with the treatment prescribed. Long-term and direct comparative studies between treatments are needed to further understand treatment differences in efficacy and safety profiles.

Transregional autologous serum eye drop provision by a large German Red Cross Blood Donation Service

BACKGROUND

The Blood Donation Service West serves North Rhine-Westphalia (NRW), Rhineland-Palatinate (RP), and Saarland, an area of 56,500 km². In addition to routine red blood cell concentrates, plasma, and platelets, special products are provided. Since 2014, this has included autologous serum eye drops (ASED) for topical use in patients suffering from different illnesses accompanied by dry eye disease.

METHODS

A volume of 250-525 mL of patient blood was collected into an anticoagulant-free blood bag. Laboratory testing included Hepatitis B/C-, HIV 1/2-, and Lues-serology. Coagulation and centrifugation were followed by leukoreduction. Single-use vials were obtained by filling mini-bag systems using a sterile tube welder. Storage at ≤-20 °C enabled a shelf-life of up to 6 months and 30 days at 4 °C after thawing for shipment.

RESULTS

Contracts were closed with 15 ophthalmology clinics and medical practices in NRW and RP to supply patients with ASED. The patient pool increased from 19 in 2014 to 46 in 2020, with an average age of 43-55 years. Overall, blood collections almost tripled from 31 to 100 per year, increasing the stock of deliverable single-use vials from 3328 to 13,358. Delivery in a liquid state allowed engagement of 44 pharmacies located in the patient neighborhoods for continuous supply.

CONCLUSION

Manufacturing in a closed bag system allowed integration into blood bank operations. However, cost-coverage by health insurance remained a case-by-case decision. Allogeneic application as 'just-another-blood-product' could be an aspiration. Yet, conclusive data from large clinical trials are needed for licensed provision in Germany.

[Schirmer's test and strip meniscometry : Comparative consideration in the diagnostics of dry eye]

BACKGROUND

As one alternative to the Schirmer test, strip meniscometry has been presented as a methodology which also seems to be suitable for quantifying a lack of tear volume.

METHODS

In a randomized prospective clinical study 391 eyes from 201 subjects were assigned to 3 groups according to the severity of eye surface deficiency (group 0: 225 healthy eyes, f/m = 1.25, mean age = 50.1 ± 17.6 years; group 1: 112 eyes with mild keratoconjunctivitis sicca (KCS), f/m = 1.38, mean age = 58.7 ± 13.9 years; group 2: 54 eyes with manifest KCS, f/m = 2.375, mean age = 52.6 ± 14.1 years). Objective test parameters used were strip meniscometry, Schirmer's 1 test and the Jones-test. In order to determine the condition of the ocular surface and tear film more precisely, slit-lamp examination, the detection of lid-parallel conjunctival folds (LIPCOF) and optical coherence tomography (OCT) meniscometry were also performed. Subjective discomfort was objectified by using the Ocular Surface Disease Index questionnaire (OSDI).

RESULTS

The results of strip meniscometry, Schirmer's 1 test, the Jones test and OCT meniscometry were significantly lower in KCS subjects than in healthy subjects (p < 0.001), whereas the OSDI score was significantly higher (p < 0.001). The parameters strip meniscometry, Schirmer's 1 test, the Jones test and OCT meniscometry scores correlated with each other. Sensitivity and specificity of strip meniscometry ranged from 0.79 to 0.89 and from 0.42 to 0.5.

CONCLUSION

Strip meniscometry is suitable to detect a lack of tear volume. Advantageous is the rapid performance of the procedure (5 s per eye) and a good agreement with established tests (e.g. Schirmer's test). To improve the specificity, strip meniscometry must be combined with other examination methods.

Systemic Conditions Associated with Severity of Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management Study

PURPOSE

Certain systemic conditions are reported to be risk factors for dry eye disease (DED), but their associations with DED severity are not well studied. We evaluated whether systemic conditions reported to be DED risk factors are associated with severity of DED signs and symptoms.

DESIGN

Secondary analysis of data from the Dry Eye Assessment and Management Study, a large-scale multicenter randomized clinical trial of patients with moderate to severe DED.

PARTICIPANTS

Five hundred thirty-five adult patients with moderate to severe DED from 27 United States centers.

METHODS

Patients reported their medical history at baseline. They underwent ocular surface examinations and symptom evaluation using standardized protocols at baseline, 6 months, and 12 months. We analyzed the associations of systemic conditions (a systemic disease or smoking history) reported as potential DED risk factors with the severity of DED signs and symptoms using generalized linear regression models adjusted by age, gender, race, and visit.

MAIN OUTCOME MEASURES

Dry eye disease symptoms assessed using the Ocular Surface Disease Index (OSDI), 6 DED signs (tear film break-up time, anesthetized Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, tear osmolarity, and meibomian gland dysfunction), and a composite signs severity score from 0 to 1 (1 = most severe).

RESULTS

The mean age was 58 years; 81% were women. More severe DED signs were associated significantly with Sjögren syndrome (mean composite signs severity score 0.52 with disease vs. 0.43 without disease; P < 0.001), facial rosacea (0.47 vs. 0.43; P = 0.002), rheumatoid arthritis (0.47 vs. 0.42; P = 0.002), peripheral artery disease (0.50 vs. 0.43; P < 0.001), and daily smoking history (0.45 vs. 0.43; P = 0.047). Thyroid dysfunction, osteoarthritis, diabetes, irritable bowel syndrome, hypercholesterolemia, hypertension, and hypertriglyceridemia were not associated significantly with DED signs. No conditions were associated significantly with OSDI.

CONCLUSIONS

In this large, well-characterized cohort of patients with DED assessed under standardized procedures, patients with certain systemic diseases and smoking history showed more severe DED signs compared with patients without the conditions. The profile of significant DED signs varied by systemic condition, reflecting different DED causes. Understanding the systemic conditions and underlying causes that predispose some patients to severe DED can improve management.

The Impact of Surgical Excision of the Orbital Lacrimal Gland on the Aqueous Tear Production and Ocular Surface Health in Donkeys (Equus asinus)

The exact contribution of the orbital lacrimal gland (OLG) is unknown and is still a subject of debate and inconsistency in literature. Currently, there are no detailed studies addressing the influence of the OLG removal on tear production in equines. This study aimed to address the influence of surgical excision of the OLG on aqueous tear production and ocular surface health in donkeys. The study was conducted on six clinically healthy donkeys with no ophthalmic abnormalities. In each donkey, the OLG of the left eye was surgically excised, whereas the right eye was served as a control. External ophthalmic examination, Schirmer tear test (STT) I and II, tear pH, fluorescein staining test were conducted on both eyes, preoperatively and at one-week intervals for 60 days, postoperatively. There were significant decreases in STT I and II values (P = .0001 and .0001, respectively), whereas tear pH values showed a significant increase (P = .0001) in the operated eyes compared with the control ones. There were no overt clinical signs characteristics of keratoconjunctivitis sicca (KCS) in the operated eyes. However, there was evidence of microinjury of the keratoconjunctival epithelium evidenced by positive fluorescein uptake, postoperatively. Surgical excision of the OLG significantly diminished the aqueous tear production and threatened the corneal epithelium as a result of corneal dehydration. On the contrary to the recommendations of other studies, eyes subjected to this procedure should receive treatment of dry eye to prevent development of KCS, postoperatively.

Multicenter review of impression-based scleral devices

OBJECTIVE

To describe outcomes using impression based-scleral devices for the management of anterior segment disease.

METHODS

Retrospective chart review identified all patients who were fitted with impression-based scleral devices between January 1, 2013 and June 30, 2019 at three specialty contact lens practices. Patient demographic data, indication for device use, visual and physiological outcomes, as well as details of the fitting process and survival of device use were determined.

RESULTS

Forty-four patients (70 eyes) were included in the study. Primary indications for device use included corneal irregularity (28 patients, 44 eyes) and ocular surface disease (16 patients, 26 eyes). Fifty-four percent of patients had more than one ocular surface condition, and 39 % of patients had undergone at least one anterior segment surgical procedure. Twenty-nine patients had unsuccessfully attempted to wear standard scleral lenses prior to being fit with impression-based devices. Visual acuity improved significantly with impression-based devices compared to habitual correction (p < 0.001). Completion of the fitting process (including visit to acquire the impression and post-fitting assessments) required an average of 4 [1.5] visits.Ideal haptic alignment was achieved with 74 % and complete limbal clearance was achieved in 83 % of fits. Device use was discontinued due to complications in two eyes.

CONCLUSION

Patients with complex eye disease who are unable to successfully wear standard scleral lenses successfully may achieve visual and therapeutic success with impression-based devices.

Lifitegrast ophthalmic solution for treatment of ocular chronic graft-versus-host disease

Ocular chronic graft-versus-host disease (oGVHD) is a relatively common complication that occurs following allogeneic hematopoietic cell transplantation. Keratoconjunctivitis sicca (KCS) is the most common manifestation of oGVHD. Lifitegrast is a lymphocyte function-associated antigen-1 antagonist approved to reduce inflammation and symptoms in patients with dry eye disease. We evaluated the efficacy and safety of lifitegrast (5% ophthalmic solution) in patients with ocular GVHD in a single-institution retrospective cohort study of eighteen allogeneic transplant recipients who received topical lifitegrast for oGVHD treatment. The outcome of interest was improvement in oGVHD severity score by National Institutes of Health (NIH) criteria. Lifitegrast was well-tolerated and no serious adverse events were observed. Lifitegrast significantly improved NIH severity scores in 8 (44%) patients. The findings of this study suggest lifitegrast is safe, well-tolerated and is an effective option for oGVHD manifesting as KCS. Prospective evaluation is warranted to confirm efficacy of lifitegrast in this population.HighlightsIn this single-institution retrospective cohort study of eighteen patients who received allogeneic transplant between 2013 and 2018, and received topical lifitegrast for treatment of ocular GVHD, the results demonstrate that lifitegrast eye drops were well-tolerated and led to improvement in symptoms of KCS in 8 (44%) patients.Lifitegrast has the potential to fulfill an unmet need in allogeneic transplant patients with ocular GVHD. Further prospective study is warranted for confirmation.

Reduction in the inflammatory markers CD4, IL-1, IL-6 and TNFα in dogs with keratoconjunctivitis sicca treated topically with mesenchymal stem cells

Keratoconjunctivitis sicca (KCS) is of predominantly immune-mediated origin. Dogs are an excellent model for understanding this disease, as the origin of KCS in dogs is like that in humans. The objective of this study was to localize and quantify immunological markers, such as CD4 lymphocytes, interleukin (IL)-1, IL-6 and tumor necrosis factor alpha (TNFα), before and after topical treatment with mesenchymal stem cells (MSCs). Twenty-two dogs positive for KCS were topically treated with 50 μL (1 × 10⁶ MSCs) in the conjunctival sac and were evaluated for 6 months. The levels of the markers CD4, IL-6, IL-1 and TNFα were analyzed in conjunctival biopsy and cytology of the third eyelid gland by immunohistochemistry and immunocytochemistry. The results showed that before treatment, there was marked expression of all the markers (CD4, IL-6, IL-1 and TNFα), and after 6 months, there were significant (p < .05) reductions in the expression levels of all the markers. These results demonstrated that topical MSC treatment promotes a significant decrease in the expression levels of these inflammatory markers and could be used as adjuvant therapy in the treatment of KCS in dogs and humans. In addition, these markers can be excellent tools for diagnosing and analyzing the progression of KCS.

Revisiting Keratoconjunctivitis sicca associated with Human T-Cell Lymphotropic Virus Type 1: prevalence, clinical aspects and proviral load

Background

The prevalence of keratoconjunctivitis sicca (KCS) associated with Human T-Cell Lymphotropic Virus Type 1 (HTLV-1) (HTLV-1/KCS) has been estimated at around 37%, but its clinical manifestations are poorly described.

Purpose

To determine the prevalence and associated factors of HTLV-1/KCS in a large cohort of HTLV-1-infected individuals living in Salvador, Brazil.

Methods

A cross-sectional study was conducted between June 2004 and September 2017 at the Integrative and Multidisciplinary Center for HTLV in Salvador, Bahia-Brazil. Data from 758 HTLV-1-infected patients was collected. A complete ophthalmologic examination was performed in both eyes. Lacrimal function was evaluated by breakup time, Rose Bengal and Schirmer I Tests. KCS diagnosis was considered in the presence of at least two out of three positive tests. HTLV-1 proviral load Crude and Adjusted Prevalence Rates (PR) with 95% Confidence Intervals (95% CI) were estimated using multivariate Poisson Regression with robust error variance.

Results

The overall prevalence of KCS was 31.7%, with higher rates observed in HTLV-1-associated myelopathy/tropical spastic paraparesis patients (crude PR: 1.84; CI95%: 1.50–2.26) even after adjusting for age, sex, time of HTLV-1 diagnosis and schooling (adjusted PR: 1.63; CI95%: 1.31–2.02). Proviral load, low corrected visual acuity, burning and/or pain and itching were all significantly higher in patients with KCS.

Conclusion

Burning and/or pain and itching and low corrected visual acuity were the most common alterations of HTLV-1/KCS. High Proviral load was found to be associated with the presence of KCS. It is strongly recommended that HTLV-1 patients undergo periodic ophthalmologic examination to promote the early diagnosis of KCS and prevent the consequences associated with dry eye disease.

Efficacy and Safety of Wet Wipes Containing Hy-Ter® Solution Compared with Standard Care for Bilateral Posterior Blepharitis: A Preliminary Randomized Controlled Study

INTRODUCTION

A novel treatment for posterior blepharitis which involves the use of disposable wet wipes imbibed with a solution of terpinen-4-ol and hyaluronic acid (Hy-Ter^®) as well as aloe, natural anti-inflammatories and antiseptics (Blephapad Combo; Novelty Technology Care, Milan, Italy) has been proposed. The aim of this study was to compare the efficacy and safety of treatment with Blephapad Combo with standard treatment.

METHODS

We conducted 4-week, open-label, randomized controlled study with a closed sequential design at the Magna Graecia University of Catanzaro, Italy in which patients aged > 40 years with symmetrical bilateral posterior blepharitis were enrolled. Each eye represented a single experimental unit. Patients were randomly assigned using a computer-generated randomization list to apply a reusable heated compress to the eyelid of one eye before cleansing the eyelid with the Blephapad Combo wet wipe (Blephapad Combo treatment arm) or to use the standard treatment of applying a wet and warm gauze to the other eye (standard treatment arm), twice daily for 4 weeks. The primary endpoint was the percentage change from baseline to week 4 in meibomian gland dysfunction (MGD) grading scale scores.

RESULTS

Eighteen patients (9 men; 9 women) with a mean (± standard deviation) age of 66.9 ± 9.03 years were included in the study. Compared with the eye receiving the standard treatment, treatment with Blephapad Combo appeared to improve the MGD total score after 4 weeks of treatment (mean change from baseline - 29.9 vs. - 38.5%). The assessment of the investigators was that in 11 patients the eye treated with Blephapad Combo showed greater benefit, in two patients the eye treated with the standard treatment showed greater benefit and in four patients there was no difference between treatments. Blephapad Combo was well tolerated, with no serious adverse events (AEs) reported. Minor ocular AEs were reported in 44.4 and 38.9% of patients in the Blephard Combo and standard treatment arms, respectively.

CONCLUSIONS

Treatment with Blephapad Combo was more effective than the standard treatment in ameliorating MGD in patients with posterior blepharitis. Minor ocular AEs events were equally distributed between the two treatments arms.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03301844.

The Effect of Periocular Fatty Acids and 0.15% Hyaluronate Eye Drops Application on Keratoconjunctivitis Sicca in Dogs: An Exploratory Study

The aim of this exploratory study was to evaluate the efficacy of a periophthalmic cream of a pool of fatty acids (FAG®) in association with 0.15% hyaluronate eye drops in alleviating the clinical symptoms of keratoconjunctivitis sicca (KCS) in a case series of dogs. The study was conducted on 10 dogs diagnosed with idiopathic KCS. All dogs had been previously treated with topical tobramycin alone, which had been ineffective in improving clinical signs. The affected eyes were treated with 2 applications daily of a periophthalmic cream of FAG® and 1 drop 3 times a day of 0.15% of hyaluronate eye drops for 8 weeks. Schirmer tear test I (STT I) values were recorded and ocular signs (conjunctival hyperemia, ocular discharge, corneal opacity, vascularization and pigmentation, and discomfort level) were collected, scored on a 3-point scale (grade 0, grade 1, and grade 2). Differences between scores and STT data recorded at baseline and at 8 weeks of therapy were statistically analysed. The effect of treatment was pronounced (increase in STT values by more than 4 mm/min, no signs of inflammation) in 8/18 eyes; moderate (increase in STT values of 3-4 mm/min or mild improvement in signs of corneal/conjunctival inflammation) in 3/18 eyes; and unsatisfactory in 7 of 18 eyes. Median of STT values significantly improved compared with baseline levels, while statistically significant decreases in clinical-sign scores of conjunctival hyperemia, ocular discharge, and discomfort were recorded. However, in moderate and advanced stages, reduction of neovascularization or corneal pigmentation was not observed throughout the treatment period. No noticeable adverse reactions were recorded. Preliminary results indicate that the application of periocular FAG and topical 0.15% hyaluronate eye drops may be a suitable treatment for KCS in dogs in selected cases. A larger comparative study is necessary to further confirm these findings.

Manganese(III) tetrakis(1-methyl-4-pyridyl) porphyrin, a superoxide dismutase mimetic, reduces disease severity in in vitro and in vivo models for dry-eye disease

PURPOSE

To determine the efficacy of the superoxide dismutase mimetic, manganese(III) tetrakis(1-methyl-4-pyridyl) porphyrin (Mn-TM-2-PyP), in vitro in human corneal epithelial (HCE-T) cells and in vivo in a preclinical mouse model for dry-eye disease (DED).

METHODS

In vitro, HCE-T cultures were exposed either to tert-butylhydroperoxide (tBHP) to generate oxidative stress or to hyperosmolar conditions modeling cellular stress during DED. Cells were pre-treated with Mn-TM-2-PyP or vehicle. Mn-TM-2-PyP permeability across stratified HCE-T cells was assayed. In vivo, Mn-TM-2-PyP (0.1% w/v in saline) was delivered topically as eye drops in a desiccating stress/scopolamine model for DED. Preclinical efficacy was compared to untreated, vehicle- and ophthalmic cyclosporine emulsion-treated mice.

RESULTS

Mn-TM-2-PyP protected HCE-T cells in a dose-dependent manner against tBHP-induced oxidative stress as determined by calculating the IC₅₀ for tBHP in the resazurin, MTT and lactate dehydrogenase release cell viability assays. Mn-TM-2-PyP did not protect HCE-T cells from hyperosmolar insult. Its permeability coefficient across a barrier of HCE-T cells was 1.1 ± 0.05 × 10^-6 cm/s and the mass balance was 62 ± 0.6%. In vivo, topical dosing with Mn-TM-2-PyP resulted in a statistically significant reduction of corneal fluorescein staining, similar to ophthalmic cyclosporine emulsion. Furthermore, Mn-TM-2-PyP significantly reduced leukocyte infiltration into lacrimal glands and prevented degeneration of parenchymal tissue. No protective effect against loss of conjunctival goblet cells was observed. Notably, Mn-TM-2-PyP did not produce ocular toxicity when administered topically.

DISCUSSION

Our data suggest that Mn-TM-2-PyP, a prototypic synthetic metalloporphyrin compound with potent catalytic antioxidant activity, can improve signs of DED in vivo by reducing oxidative stress in corneal epithelial cells.

Ocular Surface Disease in Rodents (Guinea Pigs, Mice, Rats, Chinchillas)

This article discusses the clinical appearance, differential diagnoses, and treatment considerations of corneal disease in the most common domesticated species of rodent: mouse, rat, chinchilla, and guinea pig. Many corneal diseases are related to inbred strains of either research or pet rodents. Diseases are complicated by husbandry and treatment-related challenges in this small, social species. This article is broken down by species, first discussing normal anatomy, then discussing commonly encountered diseases, and concluding with treatment considerations.

Ocular Manifestations of Rheumatoid Arthritis: Implications of Recent Clinical Trials

While rheumatoid arthritis (RA) typically presents with synovitis of the small and medium joints of the hands, ocular manifestations of the disease are generally overlooked and largely underdiagnosed. These complications usually present in longstanding RA population and occasionally represents the first manifestation of the disease and generally affect the anterior chamber of the eye, leading to keratoconjunctivitis sicca, episcleritis, scleritis, peripheral ulcerative keratitis and anterior uveitis. In this review, we present the current understanding of the pathophysiologic mechanisms for ocular disease in RA, including the role of oxidative stress, cytokine imbalance, chronic inflammation, vascular permeability, immune complex deposition and the role of T-cells as well as the contribution of tear hyperosmolarity among other factors. We also discuss the clinical presentation and diagnosis of each of the ocular disease entities highlighting the latest strategies in the management of this serious disorders that could potentially lead to blindness and the implications of recently completed and ongoing clinical trials in the field. While RA disease control is the cornerstone in the management of RA-associated ocular manifestations, early recognition of ocular pathology with prompt referral to ophthalmology is of paramount importance in order to prevent blindness and improve the quality of life in this patient population.

One-Year Efficacy and Safety of 0.1% Cyclosporine a Cationic Emulsion in the Treatment of Severe Dry Eye Disease

Purpose

The SANSIKA study evaluated the efficacy/safety of 0.1% (1 mg/mL) cyclosporine A cationic emulsion (CsA CE) for treating dry eye disease (DED) with severe keratitis. The double-masked phase demonstrated that CsA CE was effective in reducing corneal damage and ocular surface inflammation, and was well-tolerated over 6 months. Here we report efficacy and safety findings of SANSIKA's open-label extension (OLE).

Methods

In this multicenter, double-masked, phase III study, patients with severe DED (corneal fluorescein staining [CFS] grade 4, modified Oxford scale) were randomized to once-daily CsA CE (Ikervis^®) or its vehicle for 6 months, followed by 6-month open-label, once-daily CsA CE (CsA CE/CsA CE and vehicle/CsA CE groups).

Results

A total of 177 patients completed the OLE. Efficacy results reiterated the double-masked phase: CsA CE reduced CFS score and human leukocyte antigen-antigen D related expression, improved corneal clearing, and produced continuous improvements in global symptom scores (ocular surface disease index [OSDI], visual analogue scale). The CFS-OSDI response rates (≥2 CFS points, ≥30% OSDI improvement vs baseline) at 12 vs 6 months were 39.1% vs 28.6%, respectively, for CsA CE/CsA CE and 38.0% vs 23.1% for vehicle/CsA CE. Cyclosporine A CE's safety profile was similar to the initial 6 months. The most common treatment-related treatment-emergent adverse event was instillation site pain (7.8%, CsA CE/CsA CE group; 19.0%, vehicle/CsA CE group). No unexpected safety signals were observed; systemic CsA levels were undetectable/negligible in all patients except 2 previously treated with systemic CsA.

Conclusions

In this 12-month study, once-daily CsA CE was well-tolerated and showed reductions in ocular surface inflammation and improvements in signs/symptoms in DED patients with severe keratitis.

Application of botulinum toxin in Horner's muscle for the treatment of dry eye

OBJECTIVE/METHODS

The aim of this study is to describe the use of botulinum toxin to increase tear retention in patients with dry eye, using the description of 2 cases.

RESULTS

Patients with moderate to severe dry eye that were given an injection of type A botulinum toxin in the Horner's muscle. The results at one month and 3 months are reported. An assessment was made of the subjective perception of the patient as regards any improvement, as well as taking into account, the Ocular Surface Disease Index, superficial punctate keratitis, and the time of the tear rupture and tear meniscus. A significant improvement was observed in the subjective perception of the patient, the Ocular Surface Disease Index, superficial punctate keratitis, and the time of the tear rupture and tear meniscus at one month after treatment, and the good results still being maintained at the third month. There were no adverse events.

DISCUSSION

The use of type A botulinum toxin can be considered as an alternative to increase tear retention in moderate to severe dry eye, with a good response during the first month, with an acceptable response still being maintained at the third month. Given the temporary effect of the drug, further treatments would be required.

Are Serum Vitamin D Levels Associated With Dry Eye Disease? Results From the Study Group for Environmental Eye Disease

Objectives

Dry eye disease (DED) is an increasingly important public health problem in Korea. Previous studies conducted in Korea have reported inconsistent results regarding the protective effects of vitamin D on DED, and these discrepancies may be related to the relatively simple questionnaire that has been used. Thus, we evaluated the association of serum vitamin D levels with DED using the ocular surface disease index (OSDI).

Methods

The present study evaluated data from participants in the Study Group for Environmental Eye Disease (2014-2015). This group included data from 752 participants, and data from 740 participants (253 men and 487 women) were analyzed in the present study. DED severity was evaluated using the OSDI.

Results

Higher serum vitamin D levels were associated with a non-significantly reduced risk of DED in the crude analysis (odds ratio [OR], 0.991; 95% confidence interval [CI], 0.971 to 1.011) and in the adjusted analysis (OR, 0.988; 95% CI, 0.966 to 1.010). In the crude analysis of no/mild DED vs. moderate/severe DED, men exhibited a decreased risk with increasing serum vitamin D levels (OR, 0.999; 95% CI, 0.950 to 1.051), while women exhibited an increased risk (OR, 1.003; 95% CI, 0.979 to 1.027). In these analyses, we found no significant associations.

Conclusions

The findings of the present study support previous reports that serum vitamin D levels are not associated with DED.

Efficacy and safety of using topical cyclosporine A for treatment of moderate to severe dry eye disease

Objective

To investigate and evaluate the efficacy and safety of topical cyclosporine A for treatment of moderate to severe dry eye disease.

Materials and methods

This is a prospective study of patients with moderate to severe dry eye syndrome were recruited. All cases were selected from patients attending the ophthalmic outpatient clinic of Research institute of ophthalmology. Eligible patients were at least 21 years of age with a confirmed diagnosis of keratoconjunctivitis sicca with or without Sjogren's syndrome refractory to conventional management.

The medication used in this study were unit dose vials of unpreserved cyclosporine A 0.05% used twice daily.

The protocol was composed of a 2-week washout phase, a 12-week treatment phase, and a 4-week post treatment phase. Patients were evaluated at weeks 4, 8, 12 during the treatment phase. During these visits patients were evaluated for changes from base line in Schirmer test, rose Bengal staining, superficial punctuate erosions, BUT, impression cytology, symptoms of ocular discomfort and visual acuity. After completion of the treatment phase, patients were also evaluated at post treatment week 4, during this visit patients were assessed for Schirmer test, rose Bengal staining, superficial punctuate erosion, BUT, impression cytology, symptoms of ocular discomfort and visual acuity.

Results

Thirty two cases in the mean age of 47 (12.9), range [20–67] years; four (13%) male and 28 (87%) female were recruited in the current study. Out of them, 12 (38%) cases had Sjogren syndrome. Visual acuity improved significantly (p = 0.012), BUT (p < 0.0001) for both eyes, Schirmer measurements (p < 0.0001 and p = 0.029 for OD and OS, respectively).

Conclusions

Cyclosporine A ophthalmic emulsion 0.05% has been demonstrated to be effective and safe in human clinical trials. It reduces signs and symptoms of dry eye disease, with the fact that its effect continued to occur significantly within the treatment periods as well as improvement of ocular condition kept on, actually more slowly towards stability, despite the drug has already stopped.

Assessment of corneal and conjunctival metaplasia by impression cytology during the treatment of canine keratoconjunctivitis sicca

The purpose of this study was to assess the condition of cells in the conjunctiva and corneal epithelium prior to and during cyclosporine- or tacrolimusbased treatment of keratoconjunctivitis sicca (KCS). The study was performed on 40 dogs with KCS. The dogs were divided into two groups of 20 animals each. In Group I, 0.75% cyclosporine eye drops were administered three times a day, while in Group II 0.02% tacrolimus eye drops were administered twice daily. Additionally, each group was subdivided into three subgroups based on the results of the Schirmer I tear test (STT I). Evaluation of cellular metaplasia in the cornea and the palpebral and bulbar conjunctiva based on the Nelson-Adams scale was performed by impression cytology using Millipore round filters (Millipore VSWP 01300 DA) of 25 μm pore diameter applied to the studied area. Ophthalmological and cytological examinations were performed prior to the treatment as well as after one and two months of therapy. In both groups, a decrease in Nelson-Adams values was observed, corresponding to the increasing STT values [R_xy Spearman statistically significant correlation coefficient values between -0.75 (P < 0.001) and -0.45 (P < 0.01)]. The absence of goblet cells was observed in all dogs, regardless of the KCS stage. Goblet cells reappeared following both tacrolimus- and cyclosporine-based treatment in impression cytology specimens classified as 0 in the Nelson-Adams scale. The extent of corneal and conjunctival metaplasia in the course of tacrolimus- and cyclosporine-based treatment of KCS decreases with increasing STT values.

Coping with dry eyes: a qualitative approach

Background

Dry eye is a common problem that affects many people worldwide, reducing quality of life and impacting daily activities. A qualitative approach often used in medicine and other disciplines is used to evaluate how people with dry eye cope with this impact.

Methods

Six focus group sessions were conducted at the Singapore National Eye Centre (SNEC), premises of an eye research institute. These focus groups consist of a spectrum of dry eye sufferers (30 women, 8 men, aged 61 ± 11.8 years). Standard methods of coding followed by determination of themes were adhered to. Where classification was difficult, consensus was made between 3 assessors.

Results

Audio-recorded transcripts were coded in 10 themes by 3 assessors independently. Four of the themes involved traditional measures such as lid warming, cleansing, lubrication and oral dietary supplements. The other themes discovered were Traditional Chinese Medicine, modification of eye-care habits (e.g. wearing sunglasses), environmental humidity, lifestyle (e.g. sleeping habits), psychological attitude, and lastly sharing and communication.

Conclusion

Holistic coping strategies were found to be prominent in dry eye sufferers from these focus groups, and people tend to find personalised ways of coping with the impact of dry eye on daily living.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0671-z) contains supplementary material, which is available to authorized users.

Immunohistochemical evaluation of lymphocyte populations in the nictitans glands of normal dogs and dogs with keratoconjunctivitis sicca

Idiopathic canine keratoconjunctivitis sicca (iKCS) is a common condition of the canine eye involving a deficiency in aqueous tear production which is commonly held to have an immune-mediated, as most probably an autoimmune aetiopathogenesis. Yet to date no direct evaluation has been made of the inflammatory cell populations in the lacrimal tissue of dogs with iKCS. Here we sought to quantify T and B lymphocyte populations in the lacrimal tissue of the nictitans glands of dogs with iKCS those with neurological KCS (nKCS)and also in dogs with tear production within the recognized normal levels and no ocular surface signs of KCS. Nictitans glands were obtained from 10 healthy dogs with no signs or history consistent with KCS at post-mortem or after enucleation. Nictitans glands were also obtained at parotid duct transposition surgery from ten dogs with idiopathic KCS and three with neurogenic KCS. Histological sections form the lacrimal tissue were processed immunohistochemically with primary monoclonal antibodies recognizing the T lymphocyte CD3 antigen and the B lymphocyte CD79a antigen. Cell numbers were counted in 10 randomly sampled representative high-power fields in five sections. Statistical significance of differences in cell numbers was determined using analysis of variance with significance achieved at p=0.05.Nictitans glands from dogs with iKCS showed elevated numbers of T and B lymphocytes compared with those from dogs with normal tear production. The increase in the T cell population was highly statistically significant (p=0.0025) while the increase in B cells, while statistically significant was less pronouncedly so (p=0.049). T and B lymphocyte numbers were not significantly elevated in nictitans glands from dogs with neurogenic KCS compared with those in dogs with normal tear production. The elevation in the T cell population seen in dogs with idiopathic KCS strongly supports the widely held assumption that this disease is an immune-mediated and probably autoimmune. The lack of increase in T cell populations in dogs with nKCS strongly suggests that the changes in iKCS are causing the tear deficiency and not resulting from it.

Systematic review of randomized controlled trials in the treatment of dry eye disease in Sjogren syndrome

Primary Sjögren’s syndrome is an autoimmune disease characterized by dry eye and dry mouth. We systematically reviewed all the randomized controlled clinical trials published in the last 15 years that included ocular outcomes. We found 22 trials involving 9 topical, 10 oral, 2 intravenous and 1 subcutaneous modalities of treatment. Fluoromethalone eye drops over 8 weeks were more effective than topical cyclosporine in the treatment of dry eye symptoms and signs; similarly, indomethacin eye drops over 1 month were more efficacious than diclofenac eye drops. Oral pilocarpine 5 mg twice daily over 3 months was superior to use of lubricants or punctal plugs for treating dry eye, but 5% of participants had gastrointestinal adverse effects from pilocarpine, though none discontinued treatment. In contrast, etanercept, a TNF-alpha blocking antibody, administered as subcutaneous injections twice weekly, did not improve dry eye significantly compared to placebo injections. In conclusion, topical corticosteroids have been shown to be effective in dry eye associated with Sjögren’s syndrome. As some topical non-steroidal anti-inflammatory drugs may be more effective than others, these should be further evaluated. Systemic secretagogues like pilocarpine have a role in Sjögren’s syndrome but the adverse effects may limit their clinical use. It is disappointing that systemic cytokine therapy did not produce encouraging ocular outcomes but participants should have assessment of cytokine levels in such trials, as those with higher baseline cytokine levels may respond better.

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Sjögren Syndrome: Why Do Clinical Trials Fail?

Sjögren syndrome (SS) comprises glandular and extraglandular manifestations. Double-blind prospective trials of traditional disease-modifying antirheumatic drugs and biologics have failed because they have not improved benign symptoms, the major cause of lowered quality of life. Rituximab has proven effective in SS patients with associated mixed cryoglobulinemia, parotid gland swelling, lymphocytic interstitial pneumonitis, thrombocytopenia, and other manifestations. There were few of these SS patients in the trials required for FDA approval. Most patients had benign symptoms and did not show benefit, leading to failure of the study. This article examines the reasons for these failures and proposes future directions.

Comparison between fish and linseed oils administered orally for the treatment of experimentally induced keratoconjunctivitis sicca in rabbits

The objective of this study was to compare the efficacy of two sources of omega 3 and 6, fish oil (FO) and linseed oil (LO), orally administered, alone or in combination, for treating experimentally induced keratoconjunctivitis sicca (KCS) in rabbits. Twenty-eight New Zealand rabbits were used in this study. Seven animals were allocated to the C group (negative control), and KCS was induced in 21 animals by topically applying 1% atropine sulfate drops for 7 days. Treatment with atropine was maintained throughout the study period (12 weeks). The rabbits were divided into 3 treatment groups containing 7 animals each: FO group, LO group and FLO group (FO and LO). The animals were evaluated using the Schirmer Tear Test I (STT I), Rose Bengal Test (RBT), fluorescein test (FT), tear film break-up time (TBUT), and conjunctival and histopathological analysis. There was a significant increase in STT I and TBUT values in treatment groups, but the increase occurred earlier in the FO group. The results of the RBT and FT were similar among treatment groups, except FT, in the FLO group, negative staining was only in 12 weeks. There was a significant decrease in the number of goblet cells in the FLO group compared with the other groups. The results demonstrated that orally administered of FO and LO improved the clinical signs of KCS. However, improvement occurred earlier in the FO group. Using oils in combination did not provide additional benefits. These results contribute to the future development of new oral formulations as adjuvant therapies for KCS.

Tear ferning in normal dogs and dogs with keratoconjunctivitis sicca

This study evaluates tear ferning as an ancillary technique for the evaluation of the canine tear film in normal eyes and eyes affected by keratoconjunctivitis sicca (KCS). Thirty dogs with KCS and 50 control dogs with normal tear film were evaluated with a full ophthalmoscopic examination and a Schirmer tear test type 1 (STT) determined before tear samples were obtained from the medial canthus with a microhaematocrit capillary tube. 10ul of tear was placed on a microscope slide and the time to first formation of a fern of crystallised tear solute was determined. The appearance of the ferning pattern was graded and correlated with the STT value. All eyes with KCS had abnormal ferning patterns while 39 out of the 50 normal dogs (78%) had so-called 'normal' ferning patterns. The mean STT for dogs showing 'normal' ferning patterns was 20.6mm/min for the left eye and 21.3mm/min for the right eye. STT values for eyes with 'abnormal' ferning patterns were 10.9mm/min and 12.4mm/min, these differing from the normal eyes with STT above 15mm/min significantly. These findings suggest that tear ferning could be a valuable technique for assessment of the tear film in dogs with KCS.

The Potential Role for Early Biomarker Testing as Part of a Modern, Multidisciplinary Approach to Sjögren's Syndrome Diagnosis

Sjögren's syndrome (SS) is a chronic and progressive multisystem autoimmune disease typically managed by rheumatologists. Diagnostic delays are common, due in large part to the non-specific and variable nature of SS symptoms and the slow progression of disease. The hallmark characteristics of SS are dry eye and dry mouth, but there are a broad range of other possible symptoms such as joint and muscle pain, skin rashes, chronic dry cough, vaginal dryness, extremity numbness or tingling, and disabling fatigue. Given that dry eye and dry mouth are typically the earliest presenting complaints, eye care clinicians and dental professionals are often the first point of medical contact and can provide critical collaboration with rheumatologists to facilitate both timely diagnosis and ongoing care of patients with SS. Current diagnostic criteria advocated by the American College of Rheumatology are predicated on the presence of signs/symptoms suggestive of SS along with at least two objective factors such as traditional biomarker positivity, salivary gland biopsy findings, and/or presence of keratoconjunctivitis sicca. Traditional biomarkers for SS include the autoantibodies anti-Sjögren's syndrome-related antigen A (SS-A/Ro), anti-Sjögren's syndrome-related antigen B (SS-B/La), antinuclear antibody (ANA) titers, and rheumatoid factor (RF). While diagnostically useful, these biomarkers have low specificity for SS and are not always positive, especially in early cases of SS. Several newly-identified biomarkers for SS include autoantibodies to proteins specific to the salivary and lacrimal glands [SP-1 (salivary gland protein-1), PSP (parotid secretory protein), CA-6 (carbonic anhydrase VI)]. Data suggest that these novel biomarkers may appear earlier in the course of disease and are often identified in cases that test negative to traditional biomarkers. The Sjö^® test is a commercially available diagnostic panel that incorporates testing for traditional SS biomarkers (anti-SS-A/Ro, anti-SS-B/La, ANA, and RF), as well as three novel, proprietary early biomarkers (antibodies to SP-1, PSP, and CA-6) which provide greater sensitivity and specificity than traditional biomarker testing alone. Timely diagnosis of SS requires appropriate clinical vigilance for potential SS symptoms, referral and collaborative communication among rheumatology, ophthalmology, and oral care professions, and proactive differential work-up that includes both physical and laboratory evaluations.

The prevalence and characteristics of chronic ocular itch: a cross-sectional survey

Introduction

In this cross-sectional study, we aimed to determine the prevalence and characteristics of chronic ocular itch in an outpatient ophthalmology and optometry clinic.

Methods

Four hundred patients from an outpatient ophthalmology and optometry clinic were enrolled. The presence and characteristics of chronic ocular itch were assessed by a questionnaire. Data regarding ophthalmologic, dermatologic, and systemic conditions as well as current medications were extracted from medical records.

Results

Chronic ocular itch was present in 118 (29.5%) of 400 participants. Chronic ocular pruritus was significantly more prevalent in females [P=0.015; odds ratio (OR)=1.8; 95% confidence interval (CI), 1.1-2.8] and was significantly associated with the presence of allergic conjunctivitis [51.8% (n=45); P<0.001; OR=5.0; 95% CI, 3.0-8.3], dry eye syndrome [40.1% (75); P<0.001; OR=2.6; 95% CI, 1.7-4.1], blepharitis [43.8% (n=21); P=0.021; OR=2.0; 95% CI, 1.1-3.8], and atopic dermatitis [50.0% (n=10); P=0.023; OR=2.6; 95% CI, 1.1-5.8]. Chronic ocular itch was not significantly associated with systemic conditions, or the use of prescribed ophthalmologic medications.

Discussion

Chronic ocular itch is common and may be related to ophthalmologic or dermatologic pathologies. The present findings highlight the importance of identifying and managing this uncomfortable symptom that may negatively impact the quality of life and sleep of affected patients.

Immediate Effect of 3% Diquafosol Ophthalmic Solution on Tear MUC5AC Concentration and Corneal Wetting Ability in Normal and Experimental Keratoconjunctivitis Sicca Rat Models

PURPOSE

To evaluate the immediate effect of 3% diquafosol ophthalmic solution on tear MUC5AC concentration, periodic acid-Schiff (PAS)-positive goblet cells, and tear film stability in normal and keratoconjunctivitis sicca (KCS) rat models.

METHODS

Rats were divided into normal and KCS groups. 3% of diquafosol solution was instilled into the right eye and normal saline into the left eye in both groups. To determine the peak time of tear MUC5AC concentration, tears were collected after 3% diquafosol instillation every 5 min up to 20 min. The tear film stability and the numbers of PAS-positive goblet cells were compared in both models.

RESULTS

After diquafosol instillation, tear MUC5AC concentration increased steadily for 15 min, at which point the MUC5AC concentration reached its peak. In both normal and KCS groups, the MUC5AC concentration at 15 min was higher after instillation of 3% diquafosol solution (17.77 ± 2.09 ng/ml in the normal group, 9.65 ± 3.51 ng/ml in the KCS group) than that after saline instillation (13.74 ± 2.87 ng/ml in the normal group, 8.19 ± 3.99 ng/ml in the KCS group) (p = 0.018 for both). The corneal wetting ability was significantly longer after instillation of 3% diquafosol solution compared with that after instillation of normal saline in the normal group (p = 0.018). The percentage of PAS-positive goblet cells after the instillation of 3% diquafosol solution was significantly lower than that after instillation of normal saline in both models (p = 0.018 for both).

CONCLUSIONS

Diquafosol ophthalmic solution was effective in stimulating mucin secretion in both normal and KCS rat models, and the peak time of tear MUC5AC concentration was 15 min after diquafosol instillation. The increased tear MUC5AC concentration was accompanied by improved tear film stability and a decreased percentage of PAS-positive goblet cells.

Clinical evaluation of a nutraceutical diet as an adjuvant to pharmacological treatment in dogs affected by Keratoconjunctivitis sicca

Background

Canine keratoconjunctivitis sicca (cKCS) is an inflammatory eye condition related to a deficiency in the tear aqueous fraction. Etiopathogenesis of such disease is substantially multifactorial, combining the individual genetic background with environmental factors that contribute to the process of immunological tolerance disruption and, as a consequence, to the emergence of autoimmunity disease. In this occurrence, it is of relevance the role of the physiological immune-dysregulation that results in immune-mediated processes at the basis of cKCS. Current therapies for this ocular disease rely on immunosuppressive treatments. Clinical response to treatment frequently varies from poor to good, depending on the clinical-pathological status of eyes at diagnosis and on individual response to therapy. In the light of the variability of clinical response to therapies, we evaluated the use of an anti-inflammatory/antioxidant nutraceutical diet with potential immune-modulating activity as a therapeutical adjuvant in cKCS pharmacological treatment. Such combination was administered to a cohort of dogs affected by cKCS in which the only immunosuppressive treatment resulted poorly responsive or ineffective in controlling the ocular symptoms.

Results

Fifty dogs of different breeds affected by immune-mediated cKSC were equally distributed and randomly assigned to receive either a standard diet (control, n = 25) or the nutraceutical diet (treatment group, n = 25) both combined with standard immunosuppressive therapy over a 60 days period. An overall significant improvement of all clinical parameters (tear production, conjunctival inflammation, corneal keratinization, corneal pigment density and mucus discharge) and the lack of food-related adverse reactions were observed in the treatment group (p < 0.0001).

Conclusions

Our results showed that the association of traditional immune-suppressive therapy with the antioxidant/anti-inflammatory properties of the nutraceutical diet resulted in a significant amelioration of clinical signs and symptoms in cKSC. The beneficial effects, likely due to the presence of supplemented nutraceuticals in the diet, appeared to specifically reduce the immune-mediated ocular symptoms in those cKCS-affected dogs that were poorly responsive or unresponsive to classical immunosuppressive drugs. These data suggest that metabolic changes could affect the immune response orchestration in a model of immune-mediated ocular disease, as represented by cKSC.

Comparative clinical evaluation of tacrolimus and cyclosporine eye drops for the treatment of canine keratoconjunctivitis sicca

The aim of this study was to evaluate the efficacy of tacrolimus eye drops in alleviating the clinical symptoms of canine keratoconjunctivitis sicca (KCS) and to compare this efficacy with that of cyclosporine. The clinical study was conducted on 40 dogs diagnosed with idiopathic KCS. The dogs were divided into two groups of 20 animals each. In Group I, 0.75% cyclosporine eye drops were administered three times a day, while in Group II 0.02% tacrolimus eye drops were given twice daily. In addition, each group was subdivided into three subgroups based on the results of Schirmer tear test I (STT I). Clinical and ophthalmologic examinations were performed prior to the treatment as well as after one and two months of therapy. The application of both tacrolimus and cyclosporine resulted in a significant reduction of neovascularisation after the first and second month of treatment (P < 0.05, P < 0.001); however, in moderate and advanced stages, the observed efficacy of tacrolimus was higher. Across all patients, a significant increase in STT I values was observed after both the first and second month of treatment with tacrolimus (P < 0.01), as well as after two months of treatment with cyclosporine (P < 0.05). In both groups, some patients were observed to exhibit inhibited development of pigmentation, but an analysis of particular clinical cases and statistical data revealed no statistically significant discrepancies in the course of the study. In cases of advanced canine KCS, the efficacy of tacrolimus may be higher than that of cyclosporine.

Corneal permeability changes in dry eye disease: an observational study

Background

Diagnostic tests for dry eye disease (DED), including ocular surface disease index (OSDI), tear breakup time (TBUT), corneal fluorescein staining, and lissamine staining, have great deal of variability. We investigated whether fluorophotometry correlated with previously established DED diagnostic tests and whether it could serve as a novel objective metric to evaluate DED.

Methods

Dry eye patients who have had established signs or symptoms for at least 6 months were included in this observational study. Normal subjects with no symptoms of dry eyes served as controls. Each eye had a baseline fluorescein scan prior to any fluorescein dye. Fluorescein dye was then placed into both eyes, rinsed with saline solution, and scanned at 5, 10, 15, and 30 min. Patients were administered the following diagnostic tests to correlate with fluorophotometry: OSDI, TBUT, fluorescein, and lissamine. Standard protocols were used. P < 0.05 was considered significant.

Results

Fifty eyes from 25 patients (DED = 22 eyes, 11 patients; Normal = 28 eyes, 14 patients) were included. Baseline scans of the dry eye and control groups did not show any statistical difference (p = 0.84). Fluorescein concentration of DED and normal patients showed statistical significance at all time intervals (p < 10⁻⁵, 0.001, 0.002, 0.049 for 5, 10, 15, & 30 min respectively). Fluorophotometry values converged towards baseline as time elapsed, but both groups were still statistically different at 30 min (p < 0.01). We used four fluorophotometry scoring methods and correlated them with OSDI, TBUT, fluorescein, and lissamine along with adjusted and aggregate scores. The four scoring schemes did not show any significant correlations with the other tests, except for correlations seen with lissamine and 10 (p = 0.045, 0.034) and 15 min (p = 0.013, 0.012), and with aggregate scores and 15 min (p = 0.042, 0.017).

Conclusions

Fluorophotometry generally did not correlate with any other DED tests, even though it showed capability of differentiating between DED and normal eyes up to 30 min after fluorescein dye instillation. There may be an aspect of DED that is missed in the current regimen of DED tests and only captured with fluorophotometry. Adding fluorophotometry may be useful in screening, diagnosing, and monitoring patients with DED.

Concise Review: Stem Cell Trials Using Companion Animal Disease Models

Studies to evaluate the therapeutic potential of stem cells in humans would benefit from more realistic animal models. In veterinary medicine, companion animals naturally develop many diseases that resemble human conditions, therefore, representing a novel source of preclinical models. To understand how companion animal disease models are being studied for this purpose, we reviewed the literature between 2008 and 2015 for reports on stem cell therapies in dogs and cats, excluding laboratory animals, induced disease models, cancer, and case reports. Disease models included osteoarthritis, intervertebral disc degeneration, dilated cardiomyopathy, inflammatory bowel diseases, Crohn's fistulas, meningoencephalomyelitis (multiple sclerosis-like), keratoconjunctivitis sicca (Sjogren's syndrome-like), atopic dermatitis, and chronic (end-stage) kidney disease. Stem cells evaluated in these studies included mesenchymal stem-stromal cells (MSC, 17/19 trials), olfactory ensheathing cells (OEC, 1 trial), or neural lineage cells derived from bone marrow MSC (1 trial), and 16/19 studies were performed in dogs. The MSC studies (13/17) used adipose tissue-derived MSC from either allogeneic (8/13) or autologous (5/13) sources. The majority of studies were open label, uncontrolled studies. Endpoints and protocols were feasible, and the stem cell therapies were reportedly safe and elicited beneficial patient responses in all but two of the trials. In conclusion, companion animals with naturally occurring diseases analogous to human conditions can be recruited into clinical trials and provide realistic insight into feasibility, safety, and biologic activity of novel stem cell therapies. However, improvements in the rigor of manufacturing, study design, and regulatory compliance will be needed to better utilize these models. Stem Cells 2016;34:1709-1729.

Microvascular autologous submandibular gland transplantation in severe cases of keratoconjunctivitis sicca

Dry eye syndrome is a relatively common disease of the tears and ocular surfaces that results in discomfort, visual disturbance, and tear film instability with possible damage to the ocular surfaces. Microvascular submandibular gland (SMG) transfer offers a surgical alternative for a permanent autologous substitution of tears using the basal secretion of a transplanted SMG. Long-term follow-up reveals that this technique is a lasting and effective solution for patients with severe dry eye syndrome. The uncomfortable symptoms were relieved, and the frequency of use of pharmaceutical tear substitutes was reduced. Objective examination showed significant improvement in tear film and some features of ocular surface such as breakup time of tear film and corneal staining. Patients may suffer from obstruction of Wharton's duct or epiphora after surgery. Activation of secretion-related receptors could improve the early hypofunction of the denervated SMG and prevent the duct obstruction. Reduction surgery, partial SMG transplantation, uses of atropine gel or Botulinum toxin A could be the choices of treatment for epiphora.

[Ocular graft-versus-host disease]

Ocular graft-versus-host disease (GvHD) is predominantly an inflammatory ocular surface disorder after allogeneic hematopoietic stem cell transplantation (HSCT) with increasing incidence. It is not only associated with reduced quality of life because of dry eye syndromes but can also impair visual acuity and lead to blindness due to corneal complications. The GvHD is mostly associated with severe moisturizing disorder of the ocular surface, which is often resistant to therapy and accompanied by chronic inflammation. Corneal complications are an important problem in these patients. An individually adapted multimodal stage-related and interdisciplinary therapy in cooperation with hematologists and oncologists is therefore important for the treatment of patients with ocular GvHD.

[Sjögren's syndrome - case report]

INTRODUCTION

Sjögren's syndrome (SS) is a chronic autoimmune disease that primarily affects the lacrimal and salivary exocrine glands. In children, it is a rare condition.

OBJECTIVE

To present the case of an adolescent with non-specific symptoms, but with a clinical suspicion of SS.

CASE REPORT

A male 12-year old patient, with history of arthralgias for 3 years and suspicion of xerophthalmia. Physical examination showed mild conjunctival congestion, dry mouth and hypermobility of the knees. Laboratory work: blood count and ESR were normal, antinuclear antibodies (+) > 60, Ro (+) > 60 U, and rheumatoid factor concentration (+) 160 IU / ml. SS was suspected, and a study was carried out: Schirmer test determined mild dry eye, salivary gland scintigraphy showed parotid and submandibular gland dysfunction, and salivary gland biopsy reported focal lymphocytic acinar and periductal infiltration. SS was confirmed and treated with prednisone 7.5mg/day and hydroxychloroquine 200mg/day, and local treatment, with good response.

CONCLUSIONS

The diagnostic criteria for SS in adults identified only 39% of pediatric patients, due to the low frequency of sicca symptoms. Still there are no validated diagnostic criteria for children. A good diagnosis will alleviate symptoms, prevent complications and detect associated diseases.

Evaluation of the viability of submandibular glands before and after transfer into the temporal fossa

Low tear production or elevated tear evaporation can lead to severe keratoconjunctivitis sicca. In patients with this disease, the transfer of an autologous submandibular gland into the temporal fossa is currently the most common surgical lacrimal gland substituting procedure.

AIM

We compared the pre- and postoperative viability of transferred submandibular glands.

PATIENTS, METHODS

Altogether 16 submandibular glands had been transferred in 12 patients. The graft's viability was evaluated before and 0.5-1, 1-6 and 8-12 months after transplantation by dynamic salivary gland scintigraphies after application of 40-50 MBq 99mTc-pertechnetate. Quantitative analysis was performed by calculation and comparison of the glandula submandibularis-to-background-ratio (SBR) and the transplant-to-background-ratio (TBR). The scintigraphic results were correlated with the clinical follow-up.

RESULTS

All grafts remained viable during clinical follow-up. Salivary gland scintigraphy yielded 15 true positive results and 1 false-negative result. Comparison of presurgical SBR and postsurgical TBR showed good correlation with the clinical course. In 10 patients at least one transplant-reduction was necessary due to excessive epiphora occurring averagely 8 months after transplantation.

CONCLUSION

Our results show that salivary gland scintigraphy very exactly reflects the morphological and biochemical postsurgical changes in a transferred submandibular gland. Thus, it is a reliable tool to exactly and objectively evaluate the viability of the grafts in the postsurgical course.

Recent developments on dry eye disease treatment compounds

Dry eye syndrome is a common tears and ocular surface multifactorial disease, described by changes in the ocular surface epithelia related to reduced tears quantity and ocular surface sensitivity, leading to inflammatory reaction. Managing the eye inflammation proved helpful to patients with dry eye disease and current treatment is based on the use of topically applied artificial tear products/lubricants, tear retention management, stimulation of tear secretion and using anti-inflammatory drugs. In this article we revise the corresponding literature and patents assembling the new treatment approaches of novel and future pharmaceutical compounds destined for the dry eye disease treatment. The most frequent categories of compounds presented are secretagogues and anti-inflammatory drugs. These compounds are the research outcome of novel therapeutic strategies designed to reduce key inflammatory pathways and restore healthy tear film.

Comparison of hyaluronic acid-containing topical eye drops with carbomer-based topical ocular gel as a tear replacement in canine keratoconjunctivitis sicca: A prospective study in twenty five dogs

The aim of this study was to evaluate the efficacy of a hyaluronic acid containing eye drop in ameliorating ocular surface pathology and discomfort in canine keratoconjunctivitis sicca (KCS). Twenty five dogs with KCS treated with a topical carbomer (CA)-based tear replacement gel were moved to treatment with a hyaluronic acid (HA)-containing tear replacement eye drop. Dogs were subject to a full ophthalmic examination at the beginning of the study and after two and four weeks of treatment, Schirmer tear tests (STTs) were performed at each examination. Conjunctival hyperemia, ocular discharge and ocular irritation were evaluated and scored on a 0-3 semi-quantitative scale. Values were compared before and after 4 weeks of treatment using a paired t-test. Evaluation scores were compared using the Wilcoxon signed rank test. The transfer from CA-based to HA-containing tear replacement significantly decreased the conjunctival hyperemia score from 2.12 ± 0.73 to 1.26 ± 0.59 and ocular discomfort was lowered from 2.11 ± 0.97 to 0.93 ± 0.75. Ocular discharge was reduced from a score of 1.04 ± 0.82 to 0.70 ± 0.53, however, the decrease did not reach statistical significance. Schirmer tear test was increased with statistical significance (p < 0.001) but given that the increase was only from 5.42 ± 3.50 to 6.19 ± 3.86 mm min(-1); this was not considered clinically significant. This study demonstrated that HA-containing eye drops used twice daily in dogs with KCS had greater ameliorative effects on ocular surface health and discomfort than did CA-based topical gels used as or more frequently.

Shushkakshipaka (dry eye syndrome): A case study

Ashru-tear secretion is an integral component of the ocular surface physiology; when compromised (quantitatively or qualitatively) lead to shushkakshipaka (dry eye syndrome) with various ocular discomfort symptoms and ultimately the patient may land in corneal blindness.Local, systemic and environmental factors play a major role in its pathogenisis. Vata& Pitta/Rakta vitiation as per Ayurvedic view point are the major contributing pathological factors in its manifestation. Contrary to the available modern medical treatment / management regimen; Ayurveda propounds a systematic systemic/ holistic treatment approach in the treatment of dry eye syndrome. A patient of shushkakshipaka was treated with such treatment protocol, is presented as a case study in this article.