Tear-film-oriented diagnosis for dry eye

Characteristics of dry eye associated with autoimmune diseases

PURPOSE

To investigate the characteristics of dry eye in patients with autoimmune disease.

STUDY DESIGN

Retrospective clinical study.

METHODS

Two hundred and fifty-two eyes from 252 patients (12 men and 240 women, mean age 59.8 ±15.2) with autoimmune disease and dry eye were enrolled. Patients were divided into three groups: primary Sjogren's syndrome, secondary Sjogren's syndrome, and autoimmune disease without Sjogren's syndrome.

RESULTS

Among all cases, the mean fluorescein breakup time (FBUT) was 2.7 ± 1.6 s, the van Bijesterveld corneal score was 0.8 ± 0.8, the conjunctival score was 1.5 ± 1.7; and the Schirmer 1 test value was 8.4 ± 8.2 mm. Among all cases, the fluorescein breakup pattern (FBUPs) was tear-deficiency-type dry eye in 43% of eyes (area 11%, line 32%), and short FBUT-type dry eye in 57% (dimple 31%, spot 10%, random 16%). Conjunctival scores showed significant positive correlations with anti-SS-A and anti-SS-B antibody titers in the primary and secondary Sjogren's syndrome groups.

CONCLUSION

More than half of the dry eyes associated with autoimmune diseases were short FBUT-type. Patients with autoimmune disease should be aware of dry eye, even without a diagnosis of Sjogren's syndrome.

Changes in tear cytokine and lactoferrin levels in postmenopausal women with primary acquired nasolacrimal duct obstruction complicated with obstructed meibomian gland dysfunction

BACKGROUND

Epiphora and secondary ocular surface damage are increasingly impairing the quality of life of people, particularly elderly women. We aimed to investigate the changes in tear cytokine and lactoferrin levels in postmenopausal women with primary acquired nasolacrimal duct obstruction (PANDO) complicated with obstructed meibomian gland dysfunction (OMGD) and preliminary explore the pathological mechanisms of OMGD in patients with PANDO.

METHODS

The prospective study involved 43 and 41 postmenopausal women with and without PANDO, respectively. Based on the presence or absence of OMGD, the participants were subdivided. Tear fluid was collected from affected eyes of all participants using Schirmer I test and tested for cytokine concentrations (interleukin (IL)-6, IL-8, IL-1β, interferon-gamma, tumour necrotic factor (TNF)-α, IL-10, epidermal growth factor (EGF)) using the Multiplex Luminex Assay. Tear lactoferrin levels was determined using ELISA.

RESULTS

In the PANDO with OMGD group, the IL-8, IL-1α, IL-1β, and macrophage inflammatory protein-1α levels were significantly higher than those in the other groups. The IL-6 and TNF-α levels were significantly higher than those in the controls. The lactoferrin level in the PANDO with OMGD group was lower than that in the Non-PANDO with OMGD group. The IL-10 and EGF levels were not significantly different among the groups.

CONCLUSION

The level of pro-inflammatory factors in the tears of patients with PANDO complicated with OMGD was significantly increased, which is likely to cause further damage to ocular surface. Anti-inflammatory therapy may help protect ocular surface in postmenopausal women with PANDO.

Evaluating the Efficacy of the Diluted Schirmer Method for Tear Collection in Dry Eye Syndrome Patients

PURPOSE

This study assesses the diluted Schirmer method's effectiveness in collecting tears from dry eye syndrome patients, aiming to identify the most suitable tear collection technique for them.

METHODS

A prospective study. Tear samples were collected from patients with dry eye syndrome and healthy individuals using two methods: (1) Direct Schirmer Method: Schirmer strips were directly inserted into the eye to collect tears. (2) Diluted Schirmer Method: After instilling physiological saline into the eye and waiting for 30 s to ensure thorough mixing with tears, Schirmer strips were used for collection. Tear samples from both groups were analyzed and compared for total protein and cytokine levels (IL-1β, IL-6, IL-8, TNF-α).

RESULTS

(1) The study included 32 participants: 16 with dry eye syndrome (4 males, 12 females, average age 34.92 ± 10.13 years) and 16 healthy controls (5 males, 11 females, average age 32.25 ± 9.87 years). (2) The diluted Schirmer method produced a significantly larger tear volume compared to the direct method (p < 0.05), with lower Visual Analogue Scale (VAS) scores indicating less discomfort (p < 0.05). (3) The average total protein content of the two groups was 51.70 ± 3.166 ng measured by Direct Schirmer method, and the average total protein content of the Diluted Schirmer method was 50.05 ± 3.263 ng. There was no statistical difference between the two groups. (t = 1.051, p = 0.3098) (4) The concentrations of total tear protein and various cytokines measured by both methods were higher in the dry eye group compared to the normal group, with statistically significant differences (p < 0.05). Both methods reflected consistent changes in tear protein profiles.

CONCLUSION

The diluted Schirmer method can comfortably collect an adequate volume of tear samples in a short time and consistently reflect changes in tear proteins, making it an effective method for tear collection in patients with dry eye syndrome.

Diagnostic Performance of Visionix VX120+ Platform for Dry Eye Screening

OBJECTIVE

To evaluate the accuracy of diagnosing dry eye disease (DED) by using the Visionix VX120+, to establish reference values for tear meniscus height (TMH) and non-invasive break-up time (NIBUT), and to compare the NIBUT measurements with the fluorescein tear break-up time (FBUT), Methods: fifty-eight subjects (34 dry eye and 24 control) were enrolled. The TMH, first NIBUT, and NIBUT50% were evaluated with the Visionix VX120+, and the FBUT was measured with a slit-lamp. The Receiver Operating Characteristic (ROC) curve was used to evaluate the diagnostic performance, and the Bland-Altman method was performed to analyze the agreement.

RESULTS

The areas under the curve were 0.62, 0.60, and 0.70 for the TMH, first NIBUT, and NIBUT50%, respectively. The optimal cut-off values (sensitivity, specificity) were 0.29 (0.62, 0.67), 5.05 (0.85, 0.46), and 7.35 (0.65, 0.79) for the TMH, first NIBUT, and NIBUT50%, respectively. The mean differences (lower, upper limits of agreement) were -1.10 (-8.78, 6.58) and 1.55 (-5.68, 8.78) for the first NIBUT vs. FBUT and the NIBUT50% vs. FBUT, respectively.

CONCLUSIONS

In conclusion, the NIBUT50% can be a useful tool for dry eye screening, with acceptable values of sensitivity and specificity. First, the NIBUT and NIBUT50% should not be used interchangeably with the FBUT.

Demographic and lifestyle factors associated with dry eye disease in China: A cross-sectional multi-center study

PURPOSE

Associations were assessed between demographic/lifestyle factors and tear film breakup time (TBUT) defined dry eye disease (DED) in China.

METHODS

The cross-sectional study involved 50,280 subjects (54 ± 17 y) in 217 clinics (25 provinces). Data included sleep disorders; digital screen exposure; and use of cosmetics, contact lenses, and eye drops (for asthenopia). Clinical examinations included TBUT; Schirmer I test; meibomian gland plug status. TBUT-defined DED was TBUT <10 s, with TBUT ≤5 s also considered (i.e., short TBUT-type DED), either unilateral or bilateral.

RESULTS

TBUT-defined DED was present in 81.6 % overall. The highest rates were in those 71 years or older, living in the north, with chronic daily sleep disorder, or daily cosmetic application; or daily digital screen exposure for 5 years, contact lenses 4 h, or 3 months eye drops. Compared with those without TBUT-defined DED, those with TBUT-defined DED showed lower Schirmer I results and more severe meibomian gland plug status (each, P < 0.001). Independent risk factors of DED were: aging; living in the southwest; daily digital screen exposure ≥3 h; and occasional cosmetic use. Risk factors of DED TBUT ≤5 s were: living in the southwest; wearing contact lenses (>3 y); and using eye drops. Rates of unilateral and bilateral DED were comparable.

CONCLUSIONS

DED in China is more likely in the aged and those in the north/southwest. DED rates increase with digital screen exposure, and use of cosmetics, contact lenses, or eye drops for asthenopia. Unilateral DED should be treated as promptly as bilateral.

The Distribution and Influence Factors of Non-Invasive Tear Film Break-Up Time in Children

Objective

To explore the distribution and influence factors of non-invasive tear film break-up time (NIBUT) in children.

Methods

This is a hospital-based cross-sectional study. Spherical equivalent error (SER) was measured with cycloplegia. NIBUT was measured by an ocular surface integrated analyzer.

Results

A total of 1269 children (1269 eyes) were included in this study. Participants' median age was 11 (range 6-18) years. 47.1% (598/1269) of participants were boys. The median NIBUT of myopic children and non-myopic children were 9.9 seconds (s) (Inter-quartile range, IQR: 6.4 to 16.1) and 10.9 s (IQR: 8.8 to 17.9), respectively, which was statistically significant (p = 0.004). In myopic children, 49.9% (573/1148) were able to achieve NIBUT of 10 s or more, compared to 67.8% (82/121) in non-myopic children, which was statistically significant (p < 0.001). There were 41 (3.57%) children in the myopic group and none (0%) in the non-myopic group with dry eye disease (p = 0.028). There was a positive correlation between NIBUT and age: NIBUT = 9.256 + 0.352*Age. 71.8% (824/1148) of myopic children used electronic products almost every day, compared to 37.2% (45/121) of non-myopic children, which was statistically significant (p < 0.001).

Conclusion

The NIBUT of myopic children was significantly shorter than that of non-myopic children. Children with myopia are more likely to have dry eyes. NIBUT increases with age. High frequency of electronic product use may be an important cause to NIBUT shortening in children.

Management of Dry Eye Disease for Intraocular Lens Power Calculation in Cataract Surgery: A Systematic Review

Cataracts are characterized by the crystalline lens of the eye becoming cloudy, and dry eye disease (DED) is a multifactorial disease in which the homeostasis of the tear film is lost. As the prevalence of both diseases increases with age, there is a high prevalence of DED among patients who are candidates for cataract surgery. In recent years, cataract surgery has evolved from vision restoration surgery to refractive surgery. To achieve good surgical outcomes, it is necessary to minimize postoperative refractive error in intraocular lens (IOL) power calculation, which requires accurate preoperative keratometry measurements. A stable tear film is important for the accuracy and reproducibility of keratometry measurements, and DED may have a deleterious effect. In this study, original articles that focused primarily on findings related to this topic were evaluated. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Although appropriate DED diagnoses were not presented in the articles evaluated in this review, it was confirmed that the clinical signs of DED, particularly the shortening of the tear film break-up time (TBUT), negatively impact IOL power calculations. Improvement in these clinical signs might mitigate the negative effects on these calculations.

Appropriateness of Questionnaires for the Diagnosis and Monitoring Treatment of Dry Eye Disease

Objectives: If questionnaires contributing to the diagnosis of dry eye disease are to be recommended as alternatives to existing questionnaires, they must be comparable, with similar repeatability and treatment sensitivity. Comparability was thus examined for three common dry eye questionnaires along with identifying the individual questions that most strongly predicted overall scores. Methods: Anonymised data (n = 329) collected via the Ocular Surface Disease Index (OSDI), 5-item Dry Eye Questionnaire (DEQ-5) and Symptom Assessment in Dry Eye (SANDE) questionnaires (including responses to individual questions) from consenting patients were drawn from real-world dry eye clinics/registries in the United Kingdom, Australia and New Zealand; at follow-up, normalised changes were evaluated in 54 of these patients. Treatment data were also analysed from a 6-month, randomised controlled trial assessing artificial tear supplement treatments with 43 responders and 13 non-responders to treatment identified. The questions extracted from the OSDI which form the abbreviated 6-item OSDI were also analysed. Results: The agreement between the questionnaires ranged from r = 0.577 to 0.754 (all p < 0.001). For the OSDI, three questions accounted for 89.1% of the variability in the total score. The correlation between the OSDI and OSDI-6 was r = 0.939, p < 0.001. For the DEQ-5, two questions accounted for 88.5% of the variance in the total score. Normalised treatment changes were also only moderately correlated between the questionnaires (r = 0.441 to 0.595, p < 0.01). For non-responders, variability was 7.4% with both OSDI and OSDI-6, 9.7% with DEQ-5, 12.1% with SANDE-frequency and 11.9% with SANDE-severity scale. For responders, improvement with drops was detected with a 19.1% change in OSDI, 20.2% in OSDI-6, 20.9% in DEQ-5, and 27.5%/23.6% in SANDE-frequency/severity scales. Conclusions: Existing commonly used dry eye questionnaire scores do not show high levels of correlation. The OSDI was the least variable of the questionnaires and while displaying a slightly lower treatment effect than either the DEQ or SANDE, it was more sensitive to detection of a treatment effect. The quicker-to-complete OSDI-6 exhibited essentially the same outcome as the OSDI, with similar variability and treatment sensitivity.

Dry Eye Disease: An Update on Changing Perspectives on Causes, Diagnosis, and Management

Dry eye disease is a common clinical problem encountered by ophthalmologists worldwide. Interest in this entity has increased in recent years due to the consequences it has on the ocular surface after any surface procedure. With changing times, several new factors have come to light that can influence this disease. The effect of the COVID-19 pandemic has also been greatly felt, with a range of causes, starting from increased screen work to inflammatory processes, exacerbating the condition in many. With changes in the concepts of the etiopathogenesis of the disease, a paradigm shift has taken place in the approaches to treatment. More researchers are in favor of a new tear film-oriented approach that tries to localize the disease to a single component in the tear film. Innovation of newer techniques for the treatment of meibomian gland disease has also made its foray into clinical ophthalmology. Newer drug formulations and molecules are underway to better treat the inflammatory component of the disease. Many other receptors and targets for the treatment of dry eyes are being researched. This review hopes to provide a succinct, narrative summary of the relevant research on dry eye disease to date to increase awareness about the nature and future course of this disease and its management.

Higher incidence of meibomian gland dysfunction in postmenopausal women with primary acquired nasolacrimal duct obstruction

PURPOSE

This study aimed to investigate the incidence of meibomian gland dysfunction (MGD) in postmenopausal women with primary acquired nasolacrimal duct obstruction (PANDO) and enables ophthalmologists to pay attention to ocular surface damage before surgery.

METHODS

165 postmenopausal women with PANDO and 115 postmenopausal women with a normal lacrimal drainage system were enrolled in this prospective study. Based on the results of lacrimal duct irrigation and age, the participants were further subdivided. The incidence of different severities of MGD in different groups was calculated and analyzed by the chi-squared test.

RESULTS

The incidence of MGD in the PANDO group was 81.21%, and in the control group, it was 46.96%, which was significantly higher in the presence of PANDO (p < 0.001). The incidence of severe MGD in the complete and incomplete PANDO groups was higher than that in the control group (all p < 0.05), and no significant differences were observed between the complete and incomplete PANDO groups. The incidence of moderate MGD was significantly higher in the complete PANDO group than in the control group (p < 0.001). When age was considered an independent variable, the results revealed a significant value for patients aged < 70 years (p < 0.001).

CONCLUSIONS

Our study revealed a prodominantly high incidence of MGD in postmenopausal women with PANDO, especially in a complete PANDO or aged < 70 years. Ophthalmologists need to pay close attention to MGD in postmenopausal women with PANDO.

The unique properties of tear film breakup process in patients with nasal unilateral pterygium

SIGNIFICANCE

This study found that the unique properties of tear film breakup process in eyes with pterygium, combined with ocular surface parameters, further revealed specific dynamic mechanism. It suggested that the thickness of pterygium was especially valuable in deciding the necessity of surgical management.

PURPOSE

This study aimed to explore the dynamic mechanism of tear film instability in eyes with pterygium.

METHODS

A paired-eye controlled cross-sectional study was conducted. Seventy-eight patients with nasal pterygium were enrolled. Fluorescein tear film breakup was observed. Several key parameters related to tear film quality were defined and analyzed, including total breakup area (mathematically derived from pixel size using MATLAB), breakup velocity, fluorescein breakup time, breakup location and pattern, tear meniscus height, score of fluorescein corneal staining, and meiboscore.

RESULTS

With comparable tear meniscus height, score of fluorescein corneal staining, and meiboscore between paired eyes (p > 0.05), eyes with pterygium had shorter breakup time, larger breakup area, and faster breakup velocity (p < 0.05). In eyes with pterygium, a positive correlation between meiboscore and pterygium parameters including length, thickness, and size was observed (p > 0.001). As the thickness increased, difference of breakup time and area between paired eyes increased (p = 0.02 and 0.046). Eyes with pterygium had more fixed inferonasal breakup location and often presented as dimple break (60%), whereas random break was the most common in contralateral normal eyes (62%). A unique breakup pattern named pterygium-induced local dimple break was found. It displayed as an irregular but vertical line-like shape appearing after lipid layer spreading, which was adjacent to the lower margin of pterygium and presented with unique properties including inferonasal breakup location, local breakup area, shorten breakup time, and faster breakup velocity.

CONCLUSIONS

Eyes with pterygium showed a unique tear film breakup process and novel breakup pattern named pterygium-induced local dimple break . Dynamic mechanism played a significant role in tear film instability of eyes with pterygium rather than aqueous deficiency and increased evaporation.

Dry Eye Subtype Classification Using Videokeratography and Deep Learning

We previously reported on 'Tear Film Oriented Diagnosis' (TFOD), a method for the dry eye (DE) subtype classification using fluorescein staining and an examination of fluorescein breakup patterns via slit-lamp biomicroscopy. Here, we report 'AI-supported TFOD', a novel non-invasive method for DE subtype classification using videokeratography (VK) and "Blur Value" (BV), a new VK indicator of the extent of blur in Meyer-ring images and deep learning (DL). This study involved 243 eyes of 243 DE cases (23 males and 220 females; mean age: 64.4 ± 13.9 (SD) years)-i.e., 31 severe aqueous-deficient DE (sADDE) cases, 73 mild-to-moderate ADDE (m/mADDE) cases, 84 decreased wettability DE (DWDE) cases, and 55 increased evaporation DE (IEDE) cases diagnosed via the fluorescein-supported TFOD pathway. For DL, a 3D convolutional neural network classification model was used (i.e., the original image and BV data of eyes kept open for 7 s were randomly divided into training data (146 cases) and the test data (97 cases), with the training data increased via data augmentation and corresponding to 2628 cases). Overall, the DE classification accuracy was 78.40%, and the accuracies for the subtypes sADDE, m/mADDE, DWDE, and IEDE were 92.3%, 79.3%, 75.8%, and 72.7%, respectively. 'AI-supported TFOD' may become a useful tool for DE subtype classification.

Characteristics of Pre-Lens Tear Film Behavior in Eyes Wearing Delefilcon A Silicone Hydrogel Water Gradient Contact Lenses

The pre-lens tear film (PLTF) over (i) delefilcon A silicone hydrogel water gradient (WG; 33-80% from core to surface) contact lenses (CLs) (SHWG-CLs) and (ii) subjects' own non-WG soft CLs (SCLs) (SO-SCLs) was studied in 30 eyes of 30 subjects to assess the hypothesized PLTF stabilization over SHWG-CLs. In both eyes, delefilcon A SHWG-CLs (DAILIES TOTAL1®; Alcon, Fort Worth, TX, USA) or SO-SCLs were worn. After 15 min of wearing each lens, the tear meniscus radius (TMR, mm), lipid-layer interference grade (IG) and spread grade (SG), and non-invasive breakup time (NIBUT, seconds) were evaluated and compared between the SHWG-CLs and the SO-SCLs. The comparison between the SHWG-CL and SO-SCL groups (SHWG-CL and SO-SCL, mean ± SD) revealed that TMRs temporarily decreased and reached a plateau value after 15 min (0.21 ± 0.06; 0.21 ± 0.06) compared to the value prior to CL insertion (0.24 ± 0.08; 0.25 ± 0.08), with no significant difference between the two groups. The NIBUT, IG, and SG values after 15 min of wearing the CLs were (9.7 ± 3.7; 4.7 ± 4.2), (1.0 ± 0.2; 1.8 ± 1.0), and (1.1 ± 0.4; 1.9 ± 1.5), respectively, and all values were significantly better in the SHWG-CL group (p < 0.0001, p = 0.0039, and p < 0.0001, respectively). We found that compared to the SO-SCLs, the maintenance of the PLTF on the SHWG-CLs was supported by the thicker and more stable PLTF.

Seasonality of Tear Meniscus Volume and Dry Eye-Related Symptoms - A Cross-Sectional Retrospective Cohort Study

Purpose

We aimed to determine the seasonal variation in the tear meniscus level on strip meniscometry and its association with ocular parameters and symptoms. In Japan, there are four distinct seasons characterized by marked differences in temperature and humidity, which may contribute to an observed seasonality of ocular surface symptoms.

Methods

We conducted a cross-sectional study in two Japanese clinics and recruited first-visit patients for 3 years. Tear strip meniscometry, tear break-up time (BUT), Schirmer test, and corneal staining were examined, and major ocular symptoms (dryness, irritation, pain, fatigue, blurred vision, and photophobia) were determined through interviews.

Results

The 1196 participants had a mean age of 58.9±15.2 years; 37.1% were of male sex. Strip meniscometry values and BUT revealed significant seasonality with one-way analysis of variance. The mean strip meniscometry value (mm) was 2.15±2.59 in spring (p=0.025 vs winter), 2.37±2.79 in summer (p<0.001), 2.38±2.80 in fall (p<0.001), and 1.64±2.29 in winter. Regression analysis indicated that strip meniscometry levels were correlated with BUT (p<0.001), Schirmer test values (p<0.001), corneal staining scores (p=0.022), and presence of dryness (p<0.001).

Conclusion

Strip meniscometry values exhibited distinct seasonality, being lowest in winter when the ambient condition is dry and cool, and were correlated with BUT, Schirmer test values, corneal staining scores, and the presence of subjective dryness.

Tear film lipid layer and corneal oxygenation: a new function?

The classic model of tear film is composed of mucin layer, aqueous layer and the outermost tear film lipid layer (TFLL). The complex mixture of different classes of lipids, mainly secreted by meibomian glands, gives the TFLL unique physicochemical properties. Based on these properties, several functions of TFLL have been found and/or proposed such as the resistance to evaporation and facilitating the formation of a thin film. However, the role of TFLL in the oxygenation of the cornea, a transparent avascular tissue, has never been discussed in the literature. The continuous metabolic activity of the corneal surface and the replenishment of atmospheric gas creates an O2 gradient in the tear film. The molecules of O2 must therefore be transferred from the gas phase to the liquid phase through the TFLL. This process is a function of the diffusion and solubility of the lipid layer as well as interface transfer, which is influenced by alterations in the physical state and lipid composition. In the absence of research on TFLL, the present paper aims to bring the topic into the spotlight for the first time based on existing knowledge on O2 permeability of the lipid membranes and evaporation resistance of the lipid layers. The oxidative stress generated in perturbed lipid layers and the consequent adverse effects are also covered. The function of the TFLL proposed here intends to encourage future research in both basic and clinical sciences, e.g., opening new avenues for the diagnosis and treatment of ocular surface conditions.

Changes caused by fluorescein in the tear film evaluated with hybrid break-up time test as a new method - Part Two: Its effect on breakup locations and other quantitative values

OBJECTIVES

To examine the changes caused by fluorescein in the tear film by analyzing the qualitative parameters such as breakup location and also detailed quantitative parameters.

METHODS

After determining the break-up time (BUT) value and breakup locations by the Non-invasive break-up time (NI-BUT) method, we re-evaluated the changes in the tear film stained with fluorescein using the topographical method. We called the topographic evaluation of the tear film stained with fluorescein as the Hybrid-BUT test. The results for the parameters obtained for each participant by the NI-BUT and Hybrid-BUT tests were compared.

RESULTS

Our study was conducted with 82 participants aged between 18 and 58 years (mean age 34.1 ± 11.1). The mean first break-up time value (BUT1) was 4.1 ± 2.7 s on the NI-BUT test versus 5.1 ± 3.2 s on the Hybrid-BUT test (p = 0.029). The mean average of all break-up time values (BUTAvg) for each participant was 7.2 ± 3.2 s on the NI-BUT test versus 8.4 ± 3.1 s on the Hybrid-BUT test (p = 0.004). After dividing the corneal surface into quadrants of 90°, there was no significant difference in the comparison of the locations of the first breakup (QUAD(First breakup)), the second breakup (QUAD(2nd breakup)) and the third breakup (QUAD(3rd breakup)) between the two tests (p>0.05).

CONCLUSIONS

Fluorescein affects quantitative values rather than qualitative parameters in tear film. We observed that the change caused by fluorescein in tear film break-up time could be detected objectively and in a documented manner using Hybrid-BUT test.

Evaluation of Dry Eye With Videokeratographer Using a Newly Developed Indicator

PURPOSE

To analyze the effectiveness of a newly developed indicator that quantitatively assesses disturbance in Meyer-ring (MR) images obtained via videokeratographer and assess its usefulness for the clinical evaluation of dry eye (DE).

DESIGN

Cross-sectional study.

METHODS

This study involved 79 eyes of 79 DE patients (10 males and 69 females; mean age: 62.7 years). After MR images were obtained via videokeratographer, the degree of blur was quantified at multiple points on the ring, with the total value across the cornea being defined as the disturbance value (DV). Correlations between total DV (TDV; the sum of DV for 5 seconds after eye opening) and 12 DE symptoms, Dry Eye-Related Quality of Life Score (DEQS), tear meniscus radius (mm), tear film (TF) lipid-layer spread grade (SG; grades 1-5, 1 = best), TF noninvasive breakup time (NIBUT, seconds), fluorescein breakup time (FBUT, seconds), corneal epithelial damage score (CEDS; maximum: 15 points), conjunctival epithelial damage score (CjEDS; maximum: 6 points), and Schirmer 1 test value (mm) were analyzed via univariate and multivariate analyses.

RESULTS

No significant correlations were found between TDV and each DE symptom or DEQS, yet significant correlations were found between TDV and SG, NIBUT, FBUT, CEDS, and CjEDS (r = 0.56, -0.45, -0.45, 0.72, and 0.62, respectively, all P < .01). TDV was found to be described as 2334 + (412.1 × CEDS) - (302.0 × FBUT) (R2 = 0.593, P < .0001).

CONCLUSIONS

Our newly developed indicator, DV, reflecting TF dynamics and stability and corneoconjunctival epithelial damage, may be useful for quantitatively assessing DE ocular-surface abnormalities.

Dynamic Aspects of Pre-Soft Contact Lens Tear Film and Their Relation to Dry Eye: Basic Science and Clinical Relevance

Soft contact lens (SCL) perturbs the intimate connection between the pre-lens tear film (PLTF) and the ocular surface in various ways, i.e., (i) decrease in tear meniscus radius and aqueous tear thickness, (ii) attenuation of tear film lipid layer spread, (iii) limited wettability of SCL surface, (iv) increased friction with eyelid wiper, etc. This often results in SCL-related dry eye (SCLRDE) manifested as PLTF instability and contact lens discomfort (CLD). In this review, the individual contributions of factors (i-iv) to PLTF breakup patterns (BUP) and CLD are considered via the tear film-oriented diagnosis framework adopted by the Asia Dry Eye Society from a clinical and basic science perspective. It is shown that SCLRDE (due to aqueous deficiency, increased evaporation, or decreased wettability) and BUP of PLTF classify within the same types as the ones observed for the precorneal tear film. The analysis of PLTF dynamics reveals that the inclusion of SCL enhances the manifestation of BUP associated with (i) decreased thickness of PLTF aqueous layer and (ii) limited SCL wettability as shown by the rapid expansion of BUP area. PLTF thinness and instability result in increased blink-related friction and lid wiper epitheliopathy as major contributor to CLD.

Non-invasive and objective tear film breakup detection on interference color images using convolutional neural networks

PURPOSE

Dry eye disease affects hundreds of millions of people worldwide and is one of the most common causes for visits to eye care practitioners. The fluorescein tear breakup time test is currently widely used to diagnose dry eye disease, but it is an invasive and subjective method, thus resulting in variability in diagnostic results. This study aimed to develop an objective method to detect tear breakup using the convolutional neural networks on the tear film images taken by the non-invasive device KOWA DR-1α.

METHODS

The image classification models for detecting characteristics of tear film images were constructed using transfer learning of the pre-trained ResNet50 model. The models were trained using a total of 9,089 image patches extracted from video data of 350 eyes of 178 subjects taken by the KOWA DR-1α. The trained models were evaluated based on the classification results for each class and overall accuracy of the test data in the six-fold cross validation. The performance of the tear breakup detection method using the models was evaluated by calculating the area under curve (AUC) of receiver operating characteristic, sensitivity, and specificity using the detection results of 13,471 frame images with breakup presence/absence labels.

RESULTS

The performance of the trained models was 92.3%, 83.4%, and 95.2% for accuracy, sensitivity, and specificity, respectively in classifying the test data into the tear breakup or non-breakup group. Our method using the trained models achieved an AUC of 0.898, a sensitivity of 84.3%, and a specificity of 83.3% in detecting tear breakup for a frame image.

CONCLUSIONS

We were able to develop a method to detect tear breakup on images taken by the KOWA DR-1α. This method could be applied to the clinical use of non-invasive and objective tear breakup time test.

Evaluating the Differences Between Fluorescein Tear Break-up Time and Noninvasive Measurement Techniques

OBJECTIVES

To compare fluorescein tear break-up time (BUT) and noninvasive BUT measured using interferometry and corneal topography.

METHODS

We investigated 34 eyes of 34 patients with dry eye (mean age 39.2±8.3 years) and 16 eyes of 16 non-dry eye subjects (33.5±6.5 years). Tear film stability was measured using fluorescein BUT, noninvasive BUT (NIBUT)-DR1 with an interferometer, and noninvasive keratographic BUT (NIKBUT)-first and average using corneal topography. Correlations between fluorescein BUT and noninvasive BUT parameters were determined statistically. The noninvasive BUTs were compared between the dry eye and non-dry eye groups. The agreement between fluorescein and noninvasive BUTs was described using Bland-Altman analysis.

RESULTS

Fluorescein BUT was significantly correlated with NIBUT-DR1, NIKBUT-first, and NIKBUT-average. The Bland-Altman analysis revealed bias and 95% limits of agreement between fluorescein BUT and noninvasive BUTs as follows: NIBUT-DR1: 2.07 s, -5.33 to 9.46 s; NIKBUT-first: 3.39 s, -5.46 to 12.24 s; NIKBUT-average: 6.61 s, -1.58 to 14.79 s. The noninvasive BUTs were significantly different between the two groups. When NIBUT-DR1, NIKBUT-first, and NIKBUT-average with Bland-Altman correction were used as an index for dry eye, the cut-off values were 7.1, 8.4, and 11.6 s, respectively. The sensitivities were 0.735, 0.818, and 0.727 and specificities were 0.500, 0.437, and 0.562, respectively.

CONCLUSION

Fluorescein BUT and noninvasive BUTs were significantly correlated, and noninvasive BUTs had higher values than fluorescein BUT. Considering the differences between fluorescein BUT and noninvasive BUTs, noninvasive methods can be used as effective tool for diagnosing dry eye.

Changes in the meibomian glands in postmenopausal women with primary acquired nasolacrimal duct obstruction: a prospective study

BACKGROUND

Primary acquired nasolacrimal duct obstruction (PANDO) is frequently encountered in perimenopausal women, causing tear flow stagnation and resulting in a variety of ocular discomfort symptoms. However, little is known about the alterations in the meibomian gland in postmenopausal women with PANDO. Hence, this study investigated the changes in the meibomian gland and ocular surface in postmenopausal women with PANDO.

METHODS

This prospective study included 60 eyes of 60 postmenopausal women with PANDO (PANDO group) and 30 eyes of 30 postmenopausal women without PANDO (control group). The PANDO group was further subdivided into incomplete and complete PANDO groups, based on the degree of nasolacrimal duct obstruction. The patients' symptoms were evaluated using the ocular surface disease index questionnaire. The meibomian gland and ocular surface were assessed using the Keratograph 5 M. Other ophthalmologic examinations included the tear break-up time, corneal fluorescein staining, meibomian gland expression, and Schirmer I test. The correlations between the degree of nasolacrimal duct obstruction and other metrics were analyzed.

RESULTS

The loss ratio of the upper eyelid was greater in the incomplete PANDO group than in the control group (p = 0.023). Meibomian gland distortion of the upper eyelid was more severe in the control group than in the complete PANDO group (p = 0.022). The non-invasive tear meniscus height was greater, whereas the intensity of corneal fluorescein staining was lower in the PANDO group than in the control group (all p < 0.05). The degree of nasolacrimal duct obstruction was positively associated with the non-invasive tear meniscus height and ocular surface disease index scores (p < 0.001 and p < 0.001, respectively). Corneal fluorescein staining and meibomian gland distortion of the upper eyelid were negatively correlated with the degree of nasolacrimal duct obstruction (p = 0.01 and p = 0.007, respectively).

CONCLUSION

Postmenopausal women with PANDO exhibit significant morphological changes in the meibomian gland. More attention should be paid to meibomian gland loss in postmenopausal women with incomplete PANDO, as it is crucial for identifying meibomian gland impairments in patients with PANDO.

P4 Medicine for Heterogeneity of Dry Eye: A Mobile Health-based Digital Cohort Study

During the 5th Science, Technology, and Innovation Basic Plan, the Japanese government proposed a novel societal concept -Society 5.0- that promoted a healthcare system characterized by its capability to provide unintrusive, predictive, longitudinal care through the integration of cyber and physical space. The role of Society 5.0 in managing our quality of vision will become more important in the modern digitalized and aging society, both of which are known risk factors for developing dry eye. Dry eye is the most common ocular surface disease encountered in Japan with symptoms including increased dryness, eye discomfort, and decreased visual acuity. Owing to its complexity, implementation of P4 (predictive, preventive, personalized, participatory) medicine in managing dry eye requires a comprehensive understanding of its pathology, as well as a strategy to visualize and stratify its risk factors. Using DryEyeRhythm®, a mobile health (mHealth) smartphone software (app), we established a route to collect holistic medical big data on dry eye, such as the subjective symptoms and lifestyle data for each individual. The studies to date aided in determining the risk factors for severe dry eye, the association between major depressive disorder and dry eye exacerbation, eye drop treatment adherence, app-based stratification algorithms based on symptomology, blink detection biosensoring as a dry eye-related digital phenotype, and effectiveness of app-based dry eye diagnosis support compared to traditional methods. These results contribute to elucidating disease pathophysiology and promoting preventive and effective measures to counteract dry eye through mHealth.

Successful Detection of the Characteristics of Tear Film Breakup Appearing Immediately after Eye Opening by Videokeratography with a Newly-Developed Indicator

Spot break (SB), a tear film breakup (TFBU) subtype seen in decreased wettability dry eye (DE), is characterized by a spot-like TFBU that appears immediately after eye opening. It is sometimes difficult to detect using currently available devices for evaluating non-invasive TFBU. The purpose of this study was to investigate the effectiveness of using a newly developed videokeratography indicator for detecting SB. The study involved 44 eyes of 44 DE patients (21 eyes with SB (SB group) and 23 eyes with random break in which fluorescein breakup time was ≤ 5 s (s) (RB group)). All eyes were examined using videokeratography, with digital Meyer-ring images being obtained. By calculation of the degree of luminance blur on the cornea in the Meyer-ring images, termed ‘disturbance value’ (DV), DVs at 0 s (DV(0)]), 2 s (DV(2)), and 5 s (DV(5)) after eye opening, and the changes of DV between each time, were compared between the SB and RB groups. Results: No significant differences in DV(2) and DV(5) and the rate of change between DV(2) and DV(5) were found between the two groups. However, DV(0) and rate of change between DV(0) and DV(2) in the SB group were significantly greater (p < 0.001) than those in the RB group. SB characteristics were successfully detected by videokeratography using a new videokeratography DV indicator.

Categorization of the Aqueous Deficient Dry Eye by a Cut-Off Criterion of TMH Measured with Tearscope

A decrease of the Tear Meniscus Height (TMH) has been proposed as a useful indicator for Aqueous Deficient Dry Eye (ADDE) categorization. The present study aimed to calculate a TMH cut-off criterion for the categorization or severity assessment of ADDE with the Tearscope. 200 participants with a previous Dry Eye Disease (DED) diagnosis according to TFOS DEWS-II criteria were recruited. TMH by slit-lamp illumination and Lipid Layer Pattern (LLP) with Tearscope were assessed to categorise the participants into the ADDE or the Evaporative Dry Eye (EDE) group. The ADDE group was also subdivided into Mild-moderate ADDE and Moderate-severe ADDE based on TMH with slit-lamp. Additionally, the TMH was measured by Tearscope (TMH-Tc). Receiver Operating Characteristics showed that the TMH-Tc have a diagnostic capability to differentiate between ADDE and EDE participants, and between Mild-moderate or Moderate-severe ADDE, with a cut-off value of 0.159 mm (AUC = 0.843 ± 0.035, p < 0.001; sensitivity: 86.4%; specificity: 75.4%) and 0.105 mm (AUC = 0.953 ± 0.025, p < 0.001; sensitivity: 98.1%; specificity: 80.0%), respectively. The present study proposed a cut-off criterion to differentiate between ADDE and EDE participants, or between ADDE severities through TMH assessed by Tearscope.

Changes caused by fluorescein in tear film by hybrid break-up time test- part one; on quantitative values

PURPOSE

To examine the effect of fluorescein on the tear film by measuring tear break-up time (BUT).

METHODS

In this prospective study, after determining the natural BUT value of the tear with the non-invasive break-up time (NI-BUT) method, we re-evaluated the changes in the tear film stained with fluorescein using the topographical method. The topographic evaluation of tears stained with fluorescein was called as Hybrid-BUT (H-BUT) test. The first BUT (BUT₁), the second BUT (BUT₂), the third BUT (BUT₃), the fourth BUT (BUT₄), and the fifth BUT (BUT₅) values of each participant's NI-BUT and H-BUT tests were compared.

RESULTS

The present study was conducted with 82 participants. Although the mean BUT₁ value was 4.1 ± 2.7 s in the NI-BUT test, it was 5.1 ± 3.2 s in the H-BUT test (p = 0.029). The mean BUT₂ value was 5.0 ± 3.0 s in the NI-BUT test, and 6.2 ± 3.3 s in the H-BUT test (p = 0.029). The mean BUT₃ value in the NI-BUT test was 5.8 ± 3.4 s, and 7.2 ± 3.7 s in the H-BUT test (p = 0.021). The mean BUT₄ value in the NI-BUT test was 6.2 ± 3.4 s and 7.9 ± 3.9 s in the H-BUT test (p = 0.009).

CONCLUSIONS

Fluorescein causes changes in the break-up time test, and depending on this, in the tear film pattern. These changes can be compared and detected quantitatively and objectively of the fluorescein-stained tear film with the NI-BUT test and the topographic devices by using the H-BUT test.

Multicenter prospective validation study for international chronic ocular graft-versus-host disease consensus diagnostic criteria

PURPOSE

To validate the international chronic ocular graft-versus-host disease (GVHD) diagnostic criteria (ICCGVHD) compared to the National Institute of Health diagnostic criteria 2014 (NIH2014) for chronic ocular GVHD.

METHODS

Between 2013 and 2019, the study enrolled 233 patients with or without chronic ocular GVHD combined with the presence or absence of systemic chronic GVHD in an internationally prospective multicenter and observational cohort from 9 institutions. All patients were evaluated for four clinical parameters of ICCGVHD.

RESULTS

The relation between the ICCGVHD score (0-11) and NIH2014 eye score (0-4) was relatively high (r = 0.708, 95% CI: 0.637-0.767, p < 0.001). The sensitivity and specificity of ICCGVHD for NIH 2014 for 233 patients were 94.3% (95% CI: 89.6%-98.1%) and 71.7% (95% CI: 63.0-79.5%), respectively (cutoff value of the ICCGVHD score = 6). The positive predictive value was 77.1% (95% CI: 71.1%-82.1%), and the negative predictive value was 87.0% (95% CI:81.6-92.5%). For the patients with systemic GVHD (n = 171), the sensitivity and specificity were 94.2% and 67.2%, respectively (ICCGVHD-score cutoff value = 6). By receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.903 (95% CI: 0.859-0.948). For patients without systemic GVHD (n = 62), the sensitivity and specificity were 100% and 76.7%, respectively (ICCGVHD-score cutoff value = 6). The AUC was 0.891 (95% CI 0.673-1.000).

CONCLUSIONS

Good sensitivity, specificity, predictive value and correlation were found between ICCGVHD and NIH2014. ICCGVHD scores ≥6 can be useful to diagnose ocular GVHD with or without systemic GVHD for clinical research.

A Perspective on the Use of Fluorescent Imaging to Reveal Mechanisms of Breakup

Purpose: Tear film instability, which can lead to rapid tear film breakup (TBU), is considered to be a major etiological factor in dry eye. However, experimental support for many of the proposed theories for TBU mechanisms is relatively scarce. The major aim of this perspective is to show that fluorescence studies of TBU can be used to provide experimental evidence for two proposed underlying mechanisms of TBU, evaporation and divergent flow.Methods: To understand the effects of TBU on tear film fluorescence, we show that local fluorescence is the product of three main factors: tear film thickness, fluorescein concentration and fluorescent efficiency. In divergent tear flow, tear film thickness is reduced without change in fluorescein concentration and fluorescent efficiency, thus leading to reduced fluorescence intensity. Evaporation causes decreased fluorescence mainly by self-quenching due to high fluorescein concentration. Fluorescent efficiency is reduced by quenching at high fluorescein concentration but is independent of concentration for very low fluorescein concentration; thus, comparison of high and very low concentrations of fluorescein can be used to discriminate between divergent flow and evaporation. Finally, it is shown how the fluorescent pattern can change greatly during the development of breakup.Conclusions: This analysis demonstrates that the study of tear film fluorescence in TBU and dry eye may be underutilized as additional information pertinent to clinical practice may be obtained. A better understanding of TBU mechanisms may lead to improved diagnosis and treatment of dry eye.

Impact of aging on the pathophysiology of dry eye disease: A systematic review and meta-analysis

PURPOSE

Dry eye disease (DED) is a common age-related ocular surface disease. However, it is unknown how aging influences the ocular surface microenvironment. This systematic review aims to investigate how the aging process changes the ocular surface microenvironment and impacts the development of DED.

METHODS

An article search was performed in PubMed, EMBASE, and Web of Science. 44 studies reporting on age-related ocular changes and 14 large epidemiological studies involving the prevalence of DED were identified. 8 out of 14 epidemiological studies were further analyzed with meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. Study-specific estimates (impact of aging on the prevalence of DED) were combined using one-group meta-analysis in a random-effects model.

RESULTS

Meta-analysis revealed the prevalence of DED in the elderly aged 60 years old or older was 5519 of 60107 (9.2%) and the odds ratio of aging compared to younger age was 1.313 (95% confidence interval [CI]; 1.107, 1.557). With increasing age, the integrity of the ocular surface and tear film stability decreased. Various inflammatory cells, including senescent-associated T-cells, infiltrated the ocular surface epithelium, lacrimal gland, and meibomian gland, accompanied by senescence-related changes, including accumulation of 8-OHdG and lipofuscin-like inclusions, increased expression of p53 and apoptosis-related genes, and decreased Ki67 positive cells.

CONCLUSIONS

The aging process greatly impacts the ocular surface microenvironment, consequently leading to DED.

Association between Dry Eye Parameters Depends on Tear Components

How tear components contribute to dry-eye symptoms/signs remains less well-defined. This observational cross-sectional study enrolled 4817 (F/M = 3590/1227) patients. Subjective symptoms were evaluated with the SPEED and OSDI questionnaires. Fluorescein tear breakup time (FTBUT), superficial punctate keratitis (SPK) grading, Schirmer scores, number of expressible meibomian glands (MGE), lipid layer thickness (LLT), blink/partial blink rates and meibography were recorded. Patients were divided into 4 types according to their Schirmer scores and LLT, i.e., Type 1 (N = 1494): Schirmer > 5 mm, LLT > 60 nm; Type 2 (N = 698): Schirmer > 5 mm, LLT ≤ 60 nm; Type 3 (N = 1160): Schirmer ≤ 5 mm, LLT ≤ 60 nm; Type 4 (N = 1465): Schirmer ≤ 5 mm, LLT > 60 nm. Lipid deficiency (LLT ≤ 60 nm) and aqueous deficiency (Schirmer score ≤ 5 mm) were found in 38.6% and 54.5% of patients, respectively. The majority (62.4%) of lipid-deficient patients were also aqueous deficient, while 44.2% of aqueous-deficient patients were also lipid-deficient. Type 3 patients (mixed type) had the highest symptom scores (p = 0.008 and 0.007 for SPEED and OSDI, respectively), more total blinks (p < 0.001) and the shortest FTBUT (p < 0.001). Stepwise multiple regression demonstrated that LLT and Schirmer score were significant contributors to FTBUT in all 4 types. The FTBUT correlated with SPK severity in all 4 types, with Schirmer score in types 1 and 4, and with LLT in type 3 patients. SPK correlated with LLT and MGE in types 1 and 4. Age correlated with dry eye parameters more significantly than sex. Subtyping by aqueous and lipid components facilitates the understanding of dry eye pathophysiology.

Decrease of tear break-up time at Japanese eye clinics during five consecutive years

The aim of this retrospective chart review study was to evaluate the 5-year trend of ocular surface examination results in participants who visited the eye clinic from 2015 to 2019, underwent corneal and lacrimal examinations, refraction, and intra-ocular pressure measurements, and reported six dry eye-related symptoms. A total of 1468 patients were analyzed. Tear break-up time (BUT) decreased continuously for five consecutive years: 4.76 ± 1.84 s in 2015, 4.57 ± 1.70 s in 2016 (p = 0.999, vs 2015), 4.35 ± 2.06 s in 2017 (p = 0.662), 3.83 ± 2.18 s in 2018 (p < 0.001), and 3.63 ± 2.10 s in 2019 (p < 0.001). The decrease of BUT was more prominent in women than men (p < 0.001) and the correlation coefficient between calendar year and BUT was greater in women than men (p = 0.002). Schirmer test value, strip tear meniscometry value, and corneal staining score did not exhibit significant changes. Prevalence of blurring, photophobia, and pain increased toward 2019 among symptoms surveyed (eye fatigue, blurring, photophobia, dryness, irritation, and pain) and regression analysis indicated blurring (p < 0.001), photophobia (p < 0.001), and pain (p < 0.001) were correlated with BUT. In conclusion, BUT decreased continuously for five consecutive years from 2015 to 2019 and was associated with dry-eye related symptoms.

Investigation of the relationship between ocular sarcoidosis and dry eye

A relationship between ocular sarcoidosis (OcSar) and dry eye (DE) has previously been reported. Here we investigated the tear function in OcSar, and the other uveitis, Vogt–Koyanagi–Harada disease (VKH), to elucidate the association between OcSar and DE. This study involved 27 eyes of 27 female OcSar patients [mean age: 67.3 ± 13.5 (SD) years], 18 eyes of 18 female VKH patients (53.1 ± 14.1 years), and 17 eyes of 17 female healthy control subjects (59.7 ± 9.6 years). In all examined eyes, tear meniscus height (TMH, mm), fluorescein breakup time (FBUT, s), scoring of keratoconjunctival epithelial damage (ED), and the Schirmer 1 test (ST1, mm/5 min) were analyzed. In the OcSar patients, VKH patients, and control subjects, the respective TMH, FBUT, ED, and ST1 values (mean ± SD) were 0.26 ± 0.10, 0.24 ± 0.09, and 0.24 ± 0.08, 4.3 ± 2.5, 7.3 ± 2.9, and 6.3 ± 3.1, 1.1 ± 1.1, 0.7 ± 0.8, and 0.1 ± 0.3, and 12.9 ± 10.5, 21.5 ± 12.1, and 24.3 ± 10.5. Statistically, the ST1 values were significantly lower in the OcSar patients than in the VKH patients (P = 0.004) and control subjects (P = 0.001). ST1 findings revealed that the neural reflex arc and lacrimal gland system, which attenuate the vicious cycle between the tear film and ocular surface epithelium in DE, are significantly impaired in OcSar cases, thus indicating a possible association between OcSar and DE.

Sodium hyaluronate combined with rhEGF contributes to alleviate clinical symptoms and Inflammation in patients with Xerophthalmia after cataract surgery

Background

To determine the effect of sodium hyaluronate combined with recombinant human epidermal growth factor (rhEGF) on clinical symptoms and inflammation in patients with newly diagnosed xerophthalmia after cataract surgery.

Methods

A total of 106 patients who underwent cataract surgery and were newly diagnosed with xerophthalmia in our hospital between June 2018 and August 2019 were enrolled. Of these, 50 patients who were treated with sodium hyaluronate (0.1%) were assigned to the monotherapy group (MG) and the remaining 56 patients who were treated with sodium hyaluronate (0.1%) combined with rhEGF (20 μg/ml) were assigned to the combination group (CG). The 2 groups were compared based on ocular surface disease index (OSDI) score, break-up time (BUT), fluorescein corneal staining level, Schirmer I test (SI) level, clinical efficacy (disappearance of typical symptoms, including eyes drying, burning sensation, foreign body sensation, etc), and interleukin (IL)-1, IL-6, and tumor necrosis factor-α (TNF-α) levels. Spearman correlation analysis was conducted to analyze the relationship between IL-1, IL-6, TNF-α and clinical efficacy. In addition, receiver operating characteristic curves were drawn to analyze the predictive value of IL-1, IL-6, and TNF-α in efficacy on xerophthalmia. Results: After treatment, the CG showed reduced OSDI score compared with the MG. The CG showed increased BUT (s) and SI (mm) levels compared with MG. After treatment, the CG exhibited decreased levels of IL-1(ng/mL), IL-6 (ng/mL), and TNF-α (ng/mL) compared with the MG. Spearman correlation analysis revealed that IL-1, IL-6, and TNF-α were negatively correlated with clinical efficacy. The areas under the curves of IL-1, IL-6, and TNF-α were 0.801, 0.800, and 0.736 respectively.

Conclusions

Sodium hyaluronate combined with rhEGF is helpful to alleviate clinical symptoms and inflammation in patients with xerophthalmia undergoing cataract surgery.

Analysis of the Association between Galectin-3 Concentration in Tears and the Severity of Dry Eye Disease: A Case-Control Study

This study aimed to investigate the relationship between the severity of dry eye disease (DED) and galectin-3 concentration (gal-3) and its cleavage (gal-3C) in tear fluid. Twenty-eight DED patients and 14 controls were recruited at Keio University Hospital. The lissamine green conjunctival staining (LG) score, fluorescein corneal staining (FL) score, tear film break-up time (TBUT), Schirmer’s test, and ocular symptoms questionnaire score (dry eye questionnaire score, DEQS) were evaluated. Furthermore, the correlation between these parameters and the concentrations of gal-3 in tears (ng/µg) and the detection rate of gal-3C (%) were analyzed. Gal-3 concentration in tears was positively correlated with the LG score (R = 0.60, p < 0.01), FL score (R = 0.49, p < 0.01), and DEQS (R = 0.45, p < 0.01), and negatively correlated with the TBUT score (R = −0.40, p < 0.01) and Schirmer’s I value (R = −0.36, p < 0.01). The detection rate of gal-3C in tears was significantly associated with the severity of DED, especially with the LG (p < 0.01) and FL (p < 0.01) scores. Therefore, the concentration of gal-3 and the detection rate of gal-3C in tears had a significant relationship with the severity of ocular surface barrier disruption.

Role of the Water Gradient Structure in Inhibiting Thin Aqueous Layer Break in Silicone Hydrogel-Soft Contact Lens

Purpose

Soft contact lenses (SCLs) are effective for refractive error correction, but prolonged wear triggers discomfort and discontinuation. This study investigates whether water gradient technology of delefilcon A-based SCLs improve tear film dynamics.

Methods

This retrospective observational study included 50 asymptomatic delefilcon A or narafilcon A users. Data on thin aqueous layer break (TALB; %), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH; mm), subjective dryness, and higher-order aberrations (HOAs) were collected. Measurements of the bare eye, the SCL-worn eye after 15 minutes (visit 1 [v1]) and 30 ± 5 days after v1 after SCL was worn for ≥5 hours (visit 2 [v2]) were recorded.

Results

TALB was significantly reduced in the delefilcon A group compared to the narafilcon A group (33.3% vs. 85.5% at v1; P < 0.0001 and 31.7% vs. 80.4% at v2; P < 0.0001). The NIBUT was also significantly higher in the former (4.2 ± 2.1 seconds vs. 2.9 ± 1.5 at v1; P < 0.01 and 4.1 ± 2.3 seconds vs. 2.7 ± 1.6 seconds at v2; P < 0.01) across both visits. The TMH was significantly reduced in the former in both v1 and v2. The total ocular HOAs were significantly lower in the former at v1 (P < 0.001) and v2 (P < 0.05) compared to the bare eye.

Conclusions

The water gradient technology of delefilcon A reduces TALB and increases NIBUT.

Translational Relevance

The use of water gradient technology improves tear film dynamics and alleviate pathological break-up pattern, improving lens performance.

Evaluation of dry eye subtypes and characteristics using conventional assessments and dynamic tear interferometry

BACKGROUND/AIMS

To evaluate subtypes and characteristics of dry eye (DE) using conventional tests and dynamic tear interferometry, and to investigate determinants of disease severity in each DE subtype.

METHODS

309 patients diagnosed with DE and 69 healthy controls were prospectively enrolled. All eyes were evaluated using Ocular Surface Disease Index (OSDI), Schirmer's test I (ST1) and Meibomian gland dysfunction (MGD) grade were analysed. The tear interferometric pattern and lipid layer thickness were determined using DR-1α and LipiView II, respectively.

RESULTS

Dynamic interferometric analysis revealed 56.6% of patients with DE exhibited Jupiter patterns, indicative of aqueous-deficiency, while 43.4% exhibited crystal patterns, indicative of lipid deficiency. These findings were in accordance with classification based on ST1 scores and MGD grade. Conventional assessment indicated 286 patients exhibited evidence of evaporative DE (EDE) due to MGD, while only 11 exhibited signs of pure aqueous-deficient DE (pure ADDE, only ST1 ≤5 mm). Interestingly, of 286 patients with EDE, 144 were categorised into the mixed-ADDE/EDE group, in which ST1 was identified as a strong negative determinant of OSDI. In contrast, 72.2% of patients with mixed-ADDE/EDE exhibited Jupiter patterns (Jupiter mixed), while 27.8% exhibited crystal patterns (crystal mixed). OSDI values were significantly higher in the crystal-mixed group than in the Jupiter mixed, in which OSDI scores were independently associated with ST1 values only.

CONCLUSIONS

Our findings indicate that majority of EDE patients also exhibit aqueous deficiency, which can aggravate symptoms even in patients with lipid-deficient mixed-ADDE/EDE. Conventional assessments should be combined with interferometric tear analysis to determine the most appropriate treatment for each DE patient.

The Effect of Sodium Hyaluronate on the Corneal Biomechanics of Patients with Cataract and Dry Eye Before Operation

Objective

The aim of this study is to analyze the effect of the artificial tear drop administration time on the regularity of the corneal surface in patients with dry eye.

Methods

Patients with cataract who were admitted to the hospital from January 2018 to December 2018 were divided into four groups (A, B, C, and D) based on their grade of noninvasive tear break-up time (NIBUT) and the concentration of the eye drops used. Groups A and C were classified as NIBUT grade 1 (NIBUTf of 6–9 s and NIBUTav of 8–13 s), and groups B and D were classified as NIBUT grade 2 (NIBUTf of <5 s and NIBUTav of ≤7 s). Groups A and B received 0.1% sodium hyaluronate eye drops, and groups C and D received 0.3% sodium hyaluronate eye drops.

Results

In group A, there was a significant increase (p < 0.05) in the surface regularity index (SRI) and the surface asymmetry index (SAI) measured 1 s after eye drop administration. In group B, there was a significant decrease (p < 0.05) in the SRI and the SAI measured 1 s and 5 and 10 min after eye drop administration. In group C, there was a significant increase (p < 0.05) in the astigmatism degree, SRI, SAI, and irregular astigmatism index (IAI) measured 1 s after eye drop administration. There was a significant decrease (p < 0.05) in potential visual acuity (PVA). In group D, there was a significant increase in the IAI and Q value (parameters of aspheric characteristics of cornea, corneal Q value) measured 1 s after eye drop administration as well as a significant decrease in PVA (p < 0.05).

Conclusion

The use of 0.1% sodium hyaluronate eye drops in patients with dry eye aid the temporary recovery of corneal surface regularity and the stability of tear film. The 0.1% sodium hyaluronate had a significant effect for the first 10 min after treatment.

Dynamics and mechanisms for tear breakup (TBU) on the ocular surface

The human tear film is rapidly established after each blink, and is essential for clear vision and eye health. This paper reviews mathematical models and theories for the human tear film on the ocular surface, with an emphasis on localized flows where the tear film may fail. The models attempt to identify the important physical processes, and their parameters, governing the tear film in health and disease.

Parameter Estimation for Mixed-Mechanism Tear Film Thinning

Etiologies of tear breakup include evaporation-driven, divergent flow-driven, and a combination of these two. A mathematical model incorporating evaporation and lipid-driven tangential flow is fit to fluorescence imaging data. The lipid-driven motion is hypothesized to be caused by localized excess lipid, or "globs." Tear breakup quantities such as evaporation rates and tangential flow rates cannot currently be directly measured during breakup. We determine such variables by fitting mathematical models for tear breakup and the computed fluorescent intensity to experimental intensity data gathered in vivo. Parameter estimation is conducted via least squares minimization of the difference between experimental data and computed answers using either the trust-region-reflective or Levenberg-Marquardt algorithm. Best-fit determination of tear breakup parameters supports the notion that evaporation and divergent tangential flow can cooperate to drive breakup. The resulting tear breakup is typically faster than purely evaporative cases. Many instances of tear breakup may have similar causes, which suggests that interpretation of experimental results may benefit from considering multiple mechanisms.

Smart Eye Camera: A Validation Study for Evaluating the Tear Film Breakup Time in Human Subjects

Purpose

This study aimed to demonstrate the efficacy of a "Smart Eye Camera (SEC)" in comparison with the efficacy of the conventional slit-lamp microscope by evaluating their diagnostic functionality for dry eye disease (DED) in clinical cases.

Methods

This retrospective study included 106 eyes from 53 adult Japanese patients who visited the Ophthalmology outpatient clinics in Keio University Hospital from June 2019 to March 2020. Tear film breakup time (TFBUT) and corneal fluorescence score (CFS) measurements for the diagnosis of DED were compared between the conventional slit-lamp microscope and SEC.

Results

The objective findings of DED showed that there was a strong correlation between the conventional slit-lamp microscope and SEC with respect to TFBUT and CFS results (Spearman's r = 0.887, 95% confidence interval [CI] = 0.838-0.922, and r = 0.920, 95% CI = 0.884-0.945, respectively). The interobserver reliability between the conventional slit-lamp microscope and SEC showed a moderate agreement (weighted Kappa κ = 0.527, 95% CI = 0.517-0.537 and κ = 0.550, 95% CI = 0.539-0.561 for TFBUT and CFS, respectively). The diagnostic performance of the SEC for Asia Dry Eye Society diagnostic criteria showed a sensitivity of 0.957 (95% CI = 0.841-0.992), specificity of 0.900 (95% CI = 0.811-0.927), positive predictive value of 0.880 (95% CI = 0.774-0.912), and negative predictive value of 0.964 (95% CI = 0.869-0.993). Moreover, the area under the receiver operating characteristic curve was 0.928 (95% CI = 0.849-1.000).

Conclusions

Compared with the conventional slit-lamp microscope, SEC has sufficient validity and reliability for diagnosing DED in the clinical setting.

Translational Relevance

The SEC can portably evaluate TFBUT in both basic research and clinical care.

Interactions of Meibum and Tears with Mucomimetic Polymers: A Hint towards the Interplay between the Layers of the Tear Film

Recent clinical findings suggest that mucomimetic polymers (MMP) can alter not only the texture of the aqueous tear but also the spreading and structure of the tear film (TF) lipid layer, thereby allowing for their synchronized performance in vivo. Thus, we aimed to evaluate in vitro (i) the capability of pharmaceutically applicable MMP to ensure the formation of post-evaporative ferning patterns (a characteristic feature of the “healthy” tear colloid) and (ii) the MMP interactions with human meibum films accessed in the course of blink-like deformations via Langmuir surface balance and Brewster angle microscopy (BAM). Four MMP were used- hyaluronic acid (HA), cross-linked hyaluronic acid (CHA), carboxymethyl cellulose (CMC) and gellan gum (GG)- at the concentrations of 0.0001%, 0.001%, 0.01%, 0.05% and 0.1%. Significant differences were observed in the MMP fern formation capability: CHA (≥0.001%) > HA (≥0.01%) = CMC (≥0.01%) > GG (≥0.05%). All MMP affected the spreading of meibum, with BAM micrographs revealing thickening of the films. CHA was particularly efficient, showing concentration-dependent enhancement of tear ferning and of meibomian layer structure, surfactant properties and viscoelasticity. Thus, endogenous and exogenous MMP may play key roles for the concerted action of the TF layers at the ocular surface, revealing novel routes for TF-oriented therapeutic applications.

Tear film break-up patterns in thyroid eye disease

Evaluation of tear film break-up pattern (TFBUP) is the main diagnostic method for tear film-oriented therapy (TFOT) of dry eye. This prospective, observational study examined TFBUPs in 154 eyes/sides from 78 patients with thyroid eye disease (TED) who met the diagnostic criteria for dry eye in Japan. TFBUPs were classified as area, line, spot, dimple, and random breaks. Results for the status of TED and dry eye were compared between the TFBUPs. Consequently, line, spot, dimple, and random breaks were observed in 80 (51.9%), 29 (18.8%), 10 (6.5%), and 35 eyes (22.7%) while no eyes showed area breaks. The random break group had the highest incidence of lid lag/Graefe sign and superior limbic keratoconjunctivitis (SLK) (P < 0.050). Although the incidence of each TFBUP is almost equal in patients with simple dry eye without TED, line breaks were more frequently observed in TED. In addition, while random breaks in simple dry eye are usually only associated with minor ocular surface damages, those in TED were associated with a higher incidence of concomitant SLK. These results will be helpful for understanding the etiology of dry eye in TED and for TFOT in TED.

Lipid conformational order and the etiology of cataract and dry eye

Lens and tear film lipids are as unique as the systems they reside in. The major lipid of the human lens is dihydrosphingomylein, found in quantity only in the lens. The lens contains a cholesterol to phospholipid molar ratio as high as 10:1, more than anywhere else in the body. Lens lipids contribute to maintaining lens clarity, and alterations in lens lipid composition due to age are likely to contribute to cataract. Lens lipid composition reflects adaptations to the unique characteristics of the lens: no turnover of lens lipids or proteins; the lowest amount of oxygen of any tissue; and contains almost no intracellular organelles. The tear film lipid layer (TFLL) is also unique. The TFLL is a thin (100 nm) layer of lipid on the surface of tears covering the cornea that contributes to tear film stability. The major lipids of the TFLL are wax esters and cholesterol esters that are not found in the lens. The hydrocarbon chains associated with the esters are longer than those found anywhere else in the body (as long as 32 carbons), and many are branched. Changes in the composition and structure of the 30,000 different moieties of TFLL contribute to the instability of tears. The focus of the current review is how spectroscopy has been used to elucidate the relationships between lipid composition, conformational order and function, and the etiology of cataract and dry eye.

Evaluation of Eye-Pain Severity between Dry-Eye Subtypes

The aim of this study was to assess eye pain between dry eye (DE) subtypes using questionnaires and the PainVision^® (Osachi) apparatus. This study involved 52 eyes of 52 DE patients with eye pain (43 females and 9 males; mean age: 64.2 ± 13.2 (mean ± SD) years) who were classified into three DE subtypes (aqueous deficient DE (ADDE); decreased wettability DE (DWDE); and increased evaporation DE (IEDE)) based on fluorescein breakup pattern. In all subjects, severity of eye pain was evaluated using PainVision^®, the DE-symptom-questionnaire visual analog scale (DSQ-VAS), and the Short-Form McGill Pain Questionnaire 2 (SF-MPQ-2). The severity of eye pain was compared between the three DE subtypes. PainVision^® findings revealed greater severity of eye pain in ADDE and DWDE than in IEDE (p < 0.05, respectively), despite no difference being found in each questionnaire. A significant correlation was found between eye pain in DSQ-VAS and continuous pain, intermittent pain, neuropathic pain, and total pain in SF-MPQ-2 (R = 0.50, 0.49, 0.47, and 0.56, respectively) (all: p < 0.001). Greater severity of eye pain was found in ADDE and DWDE than in IEDE, and PainVision^® was found useful for the objective assessment of eye pain.

Comparison and Evaluation of Prelens Tear Film Stability by Different Noninvasive in vivo Methods

Purpose

Prelens tear film stability of soft contact lens (SCL) play an important role for contact lens discomfort. In this study, we investigated the association between two types of noninvasive methods and evaluated the tear film stability with SCL using the methods.

Patients and Methods

In experiment 1, images of ring mire were recorded with a keratograph after focusing the pigment located at the front or back of the SCL. Interferometry and videokeratoscopy were used for the assessment of tear film stability in the right eye of 10 women, with two different cosmetic daily disposable SCLs: polymacon and etafilcon A with polyvinylpyrrolidone. Time to first distortion by noninvasive keratograph break up time (NIKBUT-first) was compared to noninvasive interferometry break up time (NIBUT). In experiment 2, ten normal females wore two different daily disposable SCLs: samfilcon A and narafilcon A. NIKBUT-first and NIBUT were compared between the lenses after 8 hours of SCL wearing.

Results

In experiment 1, NIBUT-first without SCL was significantly correlated to NIBUT without SCL (r=0.445, P=0.0488, Pearson’s correlation coefficients). However, NIKBUT-first with SCL was not significantly correlated with NIBUT with SCL. In experiment 2, although NIKBUT-first was not significantly different between SCLs, samfilcon A had significantly longer NIBUT than narafilcon A (P=0.0315, paired t-test).

Conclusion

NIKBUT-first with SCL could be related to tear film stability between the lens and the corneal surface, but not to prelens tear film stability. NIIBUT could be a suitable method to evaluate prelens tear stability.

Defining Dry Eye from a Clinical Perspective

Over the past decades, the number of patients with dry eye disease (DED) has increased dramatically. The incidence of DED is higher in Asia than in Europe and North America, suggesting the involvement of cultural or racial factors in DED etiology. Although many definitions of DED have been used, discrepancies exist between the various definitions of dry eye disease (DED) used across the globe. This article presents a clinical consensus on the definition of DED, as formulated in four meetings with global DED experts. The proposed new definition is as follows: “Dry eye is a multifactorial disease characterized by a persistently unstable and/or deficient tear film (TF) causing discomfort and/or visual impairment, accompanied by variable degrees of ocular surface epitheliopathy, inflammation and neurosensory abnormalities.” The key criteria for the diagnosis of DED are unstable TF, inflammation, ocular discomfort and visual impairment. This definition also recommends the assessment of ocular surface epitheliopathy and neurosensory abnormalities in each patient with suspected DED. It is easily applicable in clinical practice and should help practitioners diagnose DED consistently. This consensus definition of DED should also help to guide research and clinical trials that, to date, have been hampered by the lack of an established surrogate endpoint.

Characteristics and Utility of Fluorescein Breakup Patterns among Dry Eyes in Clinic-Based Settings

(1) Background: To evaluate the characteristics of fluorescein breakup patterns (FBUPs) among patients with dry eye disease (DED) and efficacy of FBUPs as a diagnostic test for DED subgroups. (2) Methods: The study enrolled 449 patients with DED. FBUPs were categorized as follows: area break (AB), line break (LB), spot break (SB), dimple break (DB), and random break (RB). Schirmer value, fluorescein breakup time (FBUT), keratoconjunctival score, DED subgroups and subjective symptoms were examined. (3) Results: LB patients presented with short FBUT and high keratoconjunctival score. AB patients presented with short FBUT, high cornea and keratoconjunctival scores. SB patients were young with short FBUT. DB patients exhibited low keratoconjunctival score. RB patients were young, with long FBUT and low keratoconjunctival scores. Among DED subgroups, LB and AB constituted 74.7% of aqueous-deficiency dry eye (ADDE). SB and DB constituted 42.4% of short FBUT dry eye (short FBUT-DE). Post-test probabilities and positive likelihood ratios for ADDE were 58.7% and 1.63, respectively; those for short FBUT-DE were 46.3% and 2.02, respectively. Patients with SB and AB exhibited significantly severe subjective symptoms than other FBUPs. (4) Conclusions: FBUPs are associated with both objective findings and symptoms of DED and may be a clinical tool for identification of DED subgroups.

A New Perspective on Dry Eye Classification: Proposal by the Asia Dry Eye Society

The 2017 consensus report of the Asia Dry Eye Society (ADES) on the definition and diagnosis of dry eyes described dry eye disease as "Dry eye is a multifactorial disease characterized by unstable tear film causing a variety of symptoms and/or visual impairment, potentially accompanied by ocular surface damage." The report emphasized the instability of tear film and the importance of visual dysfunction in association with dry eyes, highlighting the importance of the evaluation of tear film stability. This report also discussed the concept of tear film-oriented therapy, which stemmed from the definition, and which is centered on provision of insufficient components in each tear film layer and ocular surface epithelium. The current ADES report proposes a simple classification of dry eyes based on the concept of tear film-oriented diagnosis and suggests that there are three types of dry eye: aqueous-deficient, decreased wettability, and increased evaporation. It is suggested that these three types respectively coincide with the problems of each layer: aqueous, membrane-associated mucins, and lipid/secretory mucin. Although each component cannot be quantitatively evaluated with the current technology, a practical diagnosis based on the patterns of fluorescein breakup is recommended. The Asia Dry Eye Society classification report suggests that for a practical use of the definition, diagnostic criteria and classification system should be integrated and be simple to use. The classification system proposed by ADES is a straightforward tool and simple to use, only through use of fluorescein, which is available even to non-dry eye specialists, and which is believed to contribute to an effective diagnosis and treatment of dry eyes.