Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians

Quercetin loaded biogenic squalene nano-lipid carriers for the treatment of dry eye syndrome

In this study, quercetin-incorporated squalene nanostructured lipid carriers (QS-NLCs) were developed to mitigate the pathological conditions of dry eye disease (DED). The melt emulsification method was used to prepare QS-NLCs. The resulting NLCs have 93.74 ± 9.32 nm particle size, 43.8 ± 5.42 % drug loading and showed good stability for 90 days at different storage conditions. The structural characterization of NLCs was carried out through DSC, FTIR, and XRD, and the morphological study was conducted using TEM analysis. The morphological study emphasised no agglomeration was present in the formulation, and further -31.47 ± 2.18 mV zeta potential supported the TEM analysis. Also, the QS-NLCs showed a release pattern in which more than 70 % of the drug was released in the medium in 1 h. After that, a sustained release pattern was observed for 6 h. However, QS-NLCs also showed higher ex-vivo corneal permeation, i.e., ∼2.5-fold, as compared to free quercetin. Also, no significant difference was observed in the moisture retention capacity of NLCs when compared with control glycerin. Further, the QS-NLCs showed good anti-inflammatory and cytotoxicity activities against RAW 264.7 and HCECs cell lines, respectively. Furthermore, 18.22 ± 1.23 mm of Schirmer score in a 5-day tear production study and a 2.79-fold increased half-life (T1/2), 3.02-fold enhanced area under the curve (AUC0-∞), and 2.88-fold higher mean retention time (MRT0-∞) were obtained which signified the higher bioavailability of QS-NLCs with higher ocular tolerance ensured by modified Draize test. Most importantly, the proposed QS-NLCs improved the pharmacological activities of quercetin against DED.

Overview of Dry Eye Disease for Primary Care Physicians

Dry eye disease (DED), also known as keratoconjunctivitis sicca, is a multifactorial ocular disease characterized by tear film insufficiency due to diverse etiologies including aging, incomplete and infrequent blinking, hormonal changes, medications, and systemic diseases. Classified into aqueous-deficient dry eye (ADDE), evaporative dry eye (EDE), and mixed subtypes, DED presents with symptoms such as irritation, stinging, redness, foreign body sensation, sensitivity to light, and blurred or fluctuating vision. While rare, severe cases may lead to vision loss. With its rising global prevalence across age groups, DED poses a significant public health challenge. Primary care physicians (PCPs), often the first point of contact for DED patients, require timely screening and management strategies. This review explores the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of DED, emphasizing practical approaches for PCPs. This narrative review was conducted by searching MEDLINE, PubMed, and Google Scholar databases for relevant articles. Diagnostic approaches, including detailed history taking, patient-reported questionnaires, differential diagnosis, and assessments are discussed alongside management strategies, including symptomatic ophthalmic treatment, risk factor mitigation (e.g., reduced digital device screen time), prevention, and nutrition. By providing a synopsis of early symptoms that PCPs are often the first to encounter, practical approaches to screening and managing DED in the primary care setting, and guidelines on when to refer to specialty care, this comprehensive review aims to equip PCPs with the knowledge to improve DED screening and optimize patient outcomes.

24-month prospective randomized comparison of ab externo penetrating canaloplasty versus trabeculectomy in primary angle-closure glaucoma

PURPOSE

To report the 24-month efficacy and safety of ab externo penetrating canaloplasty compared with trabeculectomy in the treatment of primary angle-closure glaucoma (PACG).

METHODS

This is a prospective, randomized, controlled trial. Patients with PACG and inadequately controlled intraocular pressure (IOP) were recruited. Patients enrolled were randomized to either ab externo penetrating canaloplasty (PCP group) or trabeculectomy (TRAB group). The main outcome measures were intraocular pressure (IOP), number of glaucoma medications, success rate and ocular surface disease index (OSDI) questionnaire. Surgical success (definition 1) was defined as 6 mm Hg ≤ IOP ≤ 21 mm Hg with an IOP reduction of ≥ 20 % without glaucoma medications (complete success) or regardless of glaucoma medications (qualified success).

RESULTS

A total of 52 eyes (44 patients) were finally enrolled with 25 eyes in PCP group and 27 eyes in TRAB group. PCP group (85.0 %) had a similar qualified success rate compared with TRAB group (87.0 %) with definition 1 at 24 months in intention to treat (ITT) analysis (P = 1.000). In per protocol (PP) analysis, the qualified success with definition 1 were 81.3 % in PCP group and 87.0 % in TRAB group (P = 0.972). But PCP group had a lower success rate in postoperative IOP ≤ 15 mm Hg with an IOP reduction of ≥ 20 % than in TRAB group, in ITT analysis with complete success (PCP 35.0 % vs TRAB 65.2 %, P = 0.048) and PP analysis with qualified success (PCP 31.3 % vs. TRAB 69.6 %, P = 0.025). The mean OSDI score was equal in PCP group (11.9 ± 8.5) and TRAB group (16.6 ± 14.3) (P = 0.302). Hypotony-associated complications were the main complications in PCP group and TRAB group (24.0 % vs. 33.3 %, P = 0.458).

CONCLUSIONS

Compared with trabeculectomy, ab externo penetrating canaloplasty had a similar qualified success rate and comparable complications at 24 months. Without frequent bleb interventions, penetrating canaloplasty may be a promising surgery for PACG patients especially with early or mild stages.

Dry eye disease treatment improves subjective quality-of-life responses in patients with AMD, independent of disease stage

PURPOSE

To determine the impact of severity of age-related macular degeneration (AMD) on subjective treatment response in patients treated for dry eye disease.

METHODS

A total of 203 eyes diagnosed with evaporative dry eye disease (DED) due to meibomian gland dysfunction were treated using the LipiFlow or MiBoFlo systems. From this cohort, 40 eyes with stable dry AMD (early, intermediate, or late stages) were included. Each participant completed the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED) before treatment and at a 6-month follow-up. Changes in questionnaire scores were analyzed using one-way analysis of variance (ANOVA) to assess differences between AMD severity groups.

RESULTS

Improvement in SPEED and OSDI scores, including vision related OSDI scores were observed across all AMD stages, with no significant differences between groups (p<0.05).

CONCLUSION

Managing DED improved quality of life (QOL) in patients with AMD, regardless of retinal disease severity. This highlights the importance of treating coexisting ocular surface conditions to enhance patient outcomes, even in the presence of significant maculopathy.

Effect of Dietary Supplementation with Lutein, Zeaxanthin, and Elderberries on Dry Eye Disease (DED) and Immunity: A Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Dry eye disease (DED) significantly impairs quality of life, affecting physical, social, and psychological well-being, as well as reducing workplace productivity. While lutein and zeaxanthin supplements have been shown to improve ocular health, existing research often overlooks the efficacy of lower dosages and shorter durations of supplementation. This study investigated the effects of combined supplementation with lutein, zeaxanthin, and elderberries in 110 voluntary participants through a randomized controlled trial.

METHODS

Participants took 6 mg of lutein and 1 mg of zeaxanthin, along with 100 mg elderberry extract once daily for a duration of 20 days. Ocular health was assessed using the Ocular Surface Disease Index (OSDI), while immune status was evaluated with the Immune Status Questionnaire (ISQ).

RESULTS

Results showed that combined supplementation significantly (p < 0.05) reduced the OSDI scores in the intervention group from 38.15 ± 11.14 to 18.26 ± 5.57, reflecting a 52.2% reduction. A similar trend was observed with the Visual Analog Scale (VAS), indicating significant (p < 0.05) improvement from 5.31 ± 1.62 to 6.73 ± 1.74, equivalent to a 26.7% improvement. Although the intervention group showed a 15.9% improvement in ISQ scores by the study's end, this was not significantly different from the placebo group, suggesting that higher dosages or longer durations may be needed to observe a meaningful effect. Additionally, findings from the Food Frequency Questionnaire revealed that the average dietary intake of lutein and zeaxanthin among participants was only 663.49 µg, equating to just 5.5% of the suggested optimal daily intake. This low consumption is concerning, as it is inversely correlated with the risk of ocular diseases.

CONCLUSIONS

Collectively, these findings support the use of combined supplementation as an adjuvant approach to improving ocular health.

Applications of Artificial Intelligence in Diagnosis of Dry Eye Disease: A Systematic Review and Meta-Analysis

PURPOSE

Clinical diagnosis of dry eye disease is based on a subjective Ocular Surface Disease Index questionnaire or various objective tests, however, these diagnostic methods have several limitations.

METHODS

We conducted a comprehensive review of articles discussing various applications of artificial intelligence (AI) models in the diagnosis of the dry eye disease by searching PubMed, Web of Science, Scopus, and Google Scholar databases up to December 2022. We initially extracted 2838 articles, and after removing duplicates and applying inclusion and exclusion criteria based on title and abstract, we selected 47 eligible full-text articles. We ultimately selected 17 articles for the meta-analysis after applying inclusion and exclusion criteria on the full-text articles. We used the Standards for Reporting of Diagnostic Accuracy Studies to evaluate the quality of the methodologies used in the included studies. The performance criteria for measuring the effectiveness of AI models included area under the receiver operating characteristic curve, sensitivity, specificity, and accuracy. We calculated the pooled estimate of accuracy using the random-effects model.

RESULTS

The meta-analysis showed that pooled estimate of accuracy was 91.91% (95% confidence interval: 87.46-95.49) for all studies. The mean (±SD) of area under the receiver operating characteristic curve, sensitivity, and specificity were 94.1 (±5.14), 89.58 (±6.13), and 92.62 (±6.61), respectively.

CONCLUSIONS

This study revealed that AI models are more accurate in diagnosing dry eye disease based on some imaging modalities and suggested that AI models are promising in augmenting dry eye clinics to assist physicians in diagnosis of this ocular surface condition.

Prevalence of eye and adnexal disorders among elderly inmates in Taiwan prisons

BACKGROUND

Prisoner health is a topic of significant importance; however, it has received limited attention in epidemiological studies, likely because of challenges in obtaining relevant data. Specifically, research on ocular disorders among elderly prisoners is lacking. Thus, the aim of this study was to evaluate the prevalence of disorders of the eye and adnexa among elderly prisoners in Taiwan.

METHODS

We investigated the presence of eye and adnexal disorders in elderly prisoners in Taiwan using data from the Taiwan National Health Insurance Research Database. The ocular disorders were identified using the appropriate disease codes in the International Classification of Diseases, 9th revision Clinical Modification (codes 360-379). In addition, the most common types of eye and adnexal disorders among the prisoners were identified.

RESULTS

A total of 2215 elderly prisoners (age ≥ 65 years; 2073 men and 142 women) were examined. The prevalence of eye and adnexal disorders among the prisoners was 18.87%. The elderly female prisoners exhibited a higher prevalence of eye and adnexal disorders than the elderly male prisoners. The most common disorders were disorders of the conjunctiva, cataract, and disorders of the lacrimal system.

CONCLUSIONS

A considerable proportion of elderly prisoners have disorders of the eye and adnexa. The overall quality of life of elderly prisoners can be improved by addressing their visual health, which contributes to the fulfillment of their basic human rights.

Subjective dry eye symptoms and associated factors among the national general population in China during the COVID-19 pandemic: A network analysis

Background

The coronavirus disease 2019 (COVID-19) pandemic has presented numerous challenges to public health, including the emergence of subjective dry eye symptoms among individuals. However, there is currently a dearth of comprehensive knowledge regarding the associated factors with subjective dry eye symptoms in the general population.

Methods

A nationwide survey in China was carried out from 20 June to 31 August 2022, involving 21 916 participants. Subjective dry eye symptoms were assessed using the Ocular Surface Disease Index-6. We employed random forest classification to select potential associated factors based on the socioecological model. We also conducted univariate and multivariable logistic regression analyses to explore the factors associated with subjective dry eye symptoms. Network analyses were employed to explore the network structure of subjective dry eye symptoms and associated factors.

Results

The item "watching TV (or similar task)" displayed the highest node strength and exhibited the highest predictability within the network. The results of the multivariate logistic regression analysis demonstrated significant associations between subjective dry eye symptoms and several factors, including loneliness (odds ratio (OR) = 1.29; 95% confidence interval (CI) = 1.26 to 1.32), problematic Internet use (OR = 1.08; 95% CI = 1.08 to 1.09), family communication (OR = 1.01; 95% CI = 1.00 to 1.01), the presence of depression (OR = 1.53; 95% CI = 1.39 to 1.68) and anxiety (OR = 1.31; 95% CI = 1.17 to 1.47) symptoms, older age (OR = 1.01; 95% CI = 1.01 to 1.01), self-rated health status (OR = 0.99; 95% CI = 0.98 to 0.99), family health (OR = 0.97; 95% CI = 0.96 to 0.97), health literacy (OR = 0.98; 95% CI = 0.97 to 0.99) and the agreeableness personality trait (OR = 0.97; 95% CI = 0.95 to 0.99).

Conclusions

These findings have important implications for public health interventions targeting the prevention and management of subjective dry eye symptoms in the general population. Strategies addressing individual risk factors and supporting psychological well-being may prove beneficial in mitigating the burden associated with subjective dry eye symptoms.

The Combined Impact of Intense Pulsed Light Combined and 3% Diquafosol Ophthalmic Solution on Evaporative Dry Eye: A Randomized Control Study

INTRODUCTION

The primary objective of this study is to assess whether the combination of intense pulsed light (IPL) with 3% diquafosol (DQS) ophthalmic solution is more effective than intense pulsed light in alleviating signs and symptoms of dry eye disease (DED).

METHODS

This randomized study included 66 participants with evaporative dry eye (EDE) who received IPL + DQS therapy (n = 44 eyes), IPL therapy (n = 44 eyes), or sham therapy (n = 44 eyes). All participants were examined at baseline (D0), day 14 (D14), and day 28 (D28) for non-invasive break-up time (NITBUT), tear-film lipid layer (TFLL), corneal conjunctival staining (CS), meibomian gland quality (MGQ), meibomian gland expression (MGEx), and ocular surface disease index (OSDI).

RESULTS

At day 28, comparison among the IPL + DQS therapy, IPL therapy, and sham therapy found significant differences in the mean NITBUT (12.03 ± 1.27 versus 10.47 ± 3.48 versus 4.57 ± 0.46; p < 0.001), TFLL (2.09 ± 0.29 versus 2.27 ± 0.45 versus 2.89 ± 0.65; p < 0.001), CS (1.43 ± 0.82 versus 1.93 ± 1.32 versus 3.52 ± 1.00; p < 0.001), MGQ (1.55 ± 0.66 versus 1.91 ± 0.77 versus 2.66 ± 0.53; p < 0.001), MGEx (1.27 ± 0.45 versus 1.75 ± 0.44 versus 2.41 ± 0.50; p < 0.001), and OSDI score (19.36 ± 7.01 versus 24.77 ± 4.68 versus 42.61 ± 7.49; p < 0.001); significant improvements in NITBUT, TFLL, CS, MGQ, MGEx, and OSDI were found in the IPL + DQS therapy and IPL therapy, while the sham therapy had no significant improvements.

CONCLUSION

Combining 3% diquafosol ophthalmic solution with intense pulsed light was superior to IPL therapy alone in relieving the signs and symptoms of patients with severe evaporative DED.

TRIAL REGISTRATION

Clinical Trials Identifier: NCT05694026.

Dry eye disease: identification and therapeutic strategies for primary care clinicians and clinical specialists

Dry eye disease (DED) is a multifactorial disorder characterized by loss of tear film homeostasis with an estimated worldwide prevalence of 5% to 50%. In DED, dysfunction of the ocular structures that create and regulate the tear film components-including the lacrimal glands, meibomian glands, cornea, and conjunctiva-causes a qualitative and/or quantitative tear deficiency with resultant tear film instability and hyperosmolarity. This initiates a vicious cycle of ocular surface inflammation and damage that may ultimately impair the quality of life and vision of affected patients. Many factors can contribute to the development of DED, including ocular and systemic diseases, topical and systemic medications, and environmental conditions. Because DED is a chronic disorder, treatment is most often long term and may utilize both pharmacologic and nonpharmacologic interventions to address all etiologic components. The long-term management of DED can be challenging and most often should involve eye care specialist referral. However, primary care clinicians (PCCs) are often the first points of contact for patients with DED and importantly provide initial diagnosis and preliminary patient education about the disease process. Consideration of DED is also vital for the practice of various specialties due to the large number of comorbidities and medications that can contribute to DED pathogenesis and progression. Therefore, it is important that PCCs and clinical specialists be aware of the etiology of DED and its available therapeutic options. This manuscript provides an overview of DED pathophysiology and treatment and discusses specific considerations regarding DED management for PCCs and clinical specialists.Key messagesSuccessful management of dry eye disease often requires the use of various pharmacologic and/or nonpharmacologic therapies, as well as environmental and lifestyle modifications, to mitigate the underlying etiologies and restore tear film homeostasis.Primary care clinicians play an essential role in dry eye disease management by establishing a diagnosis, educating patients about the disorder, and providing referrals to eye care specialists for initiation of specialized treatment and long-term follow-up.Primary care clinicians and clinical specialists should consider prescribing medications with fewer ocular surface effects whenever possible in patients at risk for or with existing dry eye disease.

A Comprehensive Assessment of Tear-Film-Oriented Diagnosis (TFOD) in a Dacryoadenectomy Dry Eye Model

Tear film instability is a major cause of dry eye disease. In order to treat patients with short tear film breakup time (TBUT)-type dry eye, the development of tear film stabilizing agents is essential. However, the lack of an appropriate animal model of tear film instability has made drug development difficult. Although rabbit dry eye models have been reported in the past, there are only a few reports that focus on tear film instability. Herein, we assessed the tear film stability of a rabbit dry eye model induced by dacryoadenectomy. A clinical evaluation of the ocular surface, interferometry, and histological assessments of the cornea and conjunctiva were performed. Following the removal of the lacrimal glands, TBUT was shortened significantly, with dimple and random breakup patterns prominently observed. Furthermore, the blink rate in this model increased after dacryoadenectomy, suggesting that this model partially captured the phenotypes of human short TBUT-type dry eye and may be useful as an animal model for investigating potential drug candidates.

Comparison of the Ocular Surface Disease Index and the Symptom Assessment in Dry Eye Questionnaires for Dry Eye Symptom Assessment

BACKGROUND

Patient-reported dry eye symptoms (DESs), assessed using the Ocular Surface Disease Index (OSDI) and the Symptom Assessment iN Dry Eye (SANDE) questionnaires, were compared in a large sample of patients.

METHODS

The correlation (Spearman coefficient) and agreement (Bland-Altman analysis) between the OSDI and SANDE questionnaire scores (with and without score normalization) were assessed in 1033 patients and classified according to the OSDI score as non-DES and DES in a cross-sectional analysis.

RESULTS

The normalized and non-normalized SANDE results were higher than the OSDI results in all samples (2.83 ± 12.40 (p = 0.063) and 2.85 ± 15.95 (p = 0.016), respectively) and in non-DES (p > 0.063) and DES (p < 0.001) with both OSDI cutoff values. Weak correlations were found (Spearman coefficient <0.53; p < 0.001) in all cases except DES (0.12, p = 0.126). Weak agreement was found with a Bland-Altman analysis of the normalized and non-normalized scores of both questionnaires (mean difference from -7.67 ± 29.17 (DES patients) to -1.33 ± 8.99 (non-DES patients) without score normalization, and from -9.21 ± 26.37 (DES patients) to -0.85 ± 4.01 (non-DES) with data normalization), with a statistically significant linear relationship (R2 > 0.32, p < 0.001). The SANDE questionnaire did not yield the same patient classification as OSDI. The same operative curves (ROC) of the SANDE normalized and non-normalized scores were used to differentiate among patients with DES using OSDI < 12 (0.836 ± 0.015) or OSDI < 22 (0.880 ± 0.015) cutoff values.

CONCLUSIONS

Normalized and non-normalized data collected from the SANDE questionnaire showed relevant differences from those of the OSDI, which suggests that the results of the SANDE visual analog scale-based questionnaire provide different patient classifications than the OSDI score.

Prevalence and Determinants of Symptomatic Dry Eye Disease Among Adult Urban Residents of High-Altitude Areas of Southwest Saudi Arabia - A Survey

Purpose

To estimate the prevalence and determinants of Ocular Surface Disease Index (OSDI) score based dry eye disease (DED) among the adult urban population of four cities located at high altitudes in Southwest Saudi Arabia.

Methods

This cross-sectional survey was held in 2023. OSDI questionnaire was used to collect the responses of the adult participants. The score was further graded into none, mild, moderate, and severe DED to estimate age-sex-adjusted DED prevalence. The OSDI score was correlated to demographic (age group, gender, education, occupation, city) and risk factors like smoking and co-morbidities.

Results

Of the 401 adults, 388 (response rate of 97.8%) participated. The age-sex-adjusted prevalence of mild, moderate, and severe DED was 21.7%, 13.1%, and 32%, respectively. The median ODSI score was 22.9 [Interquartile range (IQR) 10.4; 47.9)]. The score was significantly higher in females (Mann-Whitney U-test P = 0.038), residents of Taif city (KW P = 0.05), those with primary/middle school education (Kruskal-Wallis P = 0.004), comorbidities like hypertension, asthma (KW P < 0.001) and risk factors like past refractive surgeries, arthritis (KW P = 0.013). Education status (P <0.001) [B = -9.0 95%] and presence of comorbidity (P = 0.022), [B = -0.823] were significant predictors of DED.

Conclusion

The prevalence of DED and severe grade was high. The level of education and presence of comorbidities significantly influenced DED in the adult urban Saudi population of cities at high altitudes.

Symptoms of dry eye related to the relative humidity of living places

PURPOSE

To investigate the impact of relative humidity (RH) and climate variables of the place of residence on symptoms of dry eye disease (DED) in primary eye care practice.

METHODS

A cross-sectional analysis of the Ocular Surface Disease Index (OSDI) dry eye classification of 1.033 patients [classified as non-DED (OSDI ≤22) and DED (OSDI >22)] was conducted in a multicentre study in Spain. Participants were classified according to the 5-year RH value (data from the Spanish Climate Agency -www.aemet.es) into two groups: those who lived in low RH (<70%) places and those who lived in high RH (≥70%) places. Additionally, differences in daily climate records (EU Copernicus Climate Change Service) were assessed.

RESULTS

The prevalence of DED symptoms was 15.5% (95% CI 13.2%-17.6%). Participants who lived in places with <70% RH showed a higher prevalence of DED (17.7%; 95% CI 14.5%-21.1%; P < 0.01 adjusted for age and sex) than those who lived in places with ≥70% RH (13.6%; 95% CI 11.1%-16.7%) and a closer, but not statistically significant, risk for DED (OR = 1.34, 95% CI 0.96 to 1.89; P = 0.09) than previously described DED risk factors [age older than 50 years (OR = 1.51, 95% CI 1.06 to 2.16; P = 0.02) and female sex (OR = 1.99, 95% CI 1.36 to 2.90; P < 0.01)]. Some climate data showed statistically significant differences (P < 0.05) between participants with DED and non-DED (mean wind gusts; atmospheric pressure; mean and minimum relative humidity); these variables did not significantly increase DED risk (OR close to 1.0 and P > 0.05).

CONCLUSION

This study is the first to describe the impact of climate data on dryness symptomatology in Spain, confirming that participants who live in locations with RH <70% have a higher prevalence (corrected for age and sex) of DED. These findings support the use of climate databases in DED research.

Efficacy of artificial tears containing trehalose and hyaluronic acid for dry eye disease in women aged 42-54 versus ≥ 55 years

BACKGROUND AND OBJECTIVES

Dry eye disease (DED) is common in postmenopausal women. This study evaluated efficacy of a 3-month daily treatment with artificial tears containing trehalose and hyaluronic acid (HA) in women aged 42-54 years (mixed-hormonal status) versus ≥ 55 years (postmenopausal) and with moderate and severe DED.

METHODS

This was a post-hoc analysis of three clinical trials assessing the efficacy of artificial tears containing trehalose (3%) and HA (0.15%) in women with an Ocular Surface Disease Index (OSDI) ≥ 18. Patients instilled one drop of the artificial tears in each eye 3 to 6 times daily and were evaluated at baseline and after 84 ± 7 days for DED symptom severity (OSDI), hyperemia (McMonnies scale), tear break-up time (TBUT), corneal and conjunctival staining (Oxford and Van Bjisterveld scales), tear production (Schirmer I test), and ocular symptoms.

RESULTS

A total of 273 women were evaluated, 61 of age 42-54 years; 212 of ≥ 55 years. DED symptoms, as measured by the OSDI, decreased significantly with the treatment in both age groups (p < 0.0001). Conjunctival hyperemia decreased significantly and TBUT increased significantly in both groups, especially in women of age 42-54 (both p < 0.0001). The global (corneal and conjunctival) staining score decreased significantly in both groups, but also more in women of age 42-54 years. No differences were observed between age groups for any of the variables measured, except for visual acuity. DED symptoms were consistently reported more frequently by the mixed hormonal status women, but also the effect of the treatment was more pronounced in this group.

CONCLUSIONS

Artificial tears with trehalose and HA significantly improved the symptoms of DED in women aged 42-54 and ≥ 55 years. The decrease in symptoms was more pronounced in women of age 42-54 years, suggesting better mechanisms of recovery from inflammation and loss of ocular surface homeostasis.

Effect of Treatment with Topical Azithromycin or Oral Doxycycline on Tear Film Thickness in Patients with Meibomian Gland Dysfunction: A Randomized Controlled Trial

Purpose: This prospective, randomized, observer-masked, parallel-group study aimed to compare the effect of topical azithromycin and oral doxycycline on tear film thickness (TFT) and signs and symptoms of ocular surface disease (OSD) in patients with meibomian gland dysfunction (MGD). Methods: Patients were randomized to either receive topical azithromycin or oral doxycycline. After a baseline visit, three follow-up visits at intervals of 2 weeks were scheduled. Main outcome of the study was change in TFT as measured with ultrahigh resolution optical coherence tomography. Results: Twenty patients were included in the analysis. TFT significantly increased in both groups (P = 0.028 vs. baseline) with no difference between the groups (P = 0.096). As secondary outcomes, ocular surface disease index (OSDI) score and composite signs of OSD significantly decreased in both groups (P = 0.023 for OSDI and P = 0.016 for OSD signs vs. baseline). While eye-related adverse events (AEs) occurred more frequently in the azithromycin group, systemic AEs were more common in the doxycycline group. Conclusions: Both treatments improved signs and symptoms of OSD in patients with MGD with no difference between the groups. Due to the higher frequency of systemic side effects of doxycycline, azithromycin eye drops seem to be an alternative with comparable efficacy. Clinical Trial Registration number: NCT03162497.

Recent Advances of Ocular Drug Delivery Systems: Prominence of Ocular Implants for Chronic Eye Diseases

Chronic ocular diseases can seriously impact the eyes and could potentially result in blindness or serious vision loss. According to the most recent data from the WHO, there are more than 2 billion visually impaired people in the world. Therefore, it is pivotal to develop more sophisticated, long-acting drug delivery systems/devices to treat chronic eye conditions. This review covers several drug delivery nanocarriers that can control chronic eye disorders non-invasively. However, most of the developed nanocarriers are still in preclinical or clinical stages. Long-acting drug delivery systems, such as inserts and implants, constitute the majority of the clinically used methods for the treatment of chronic eye diseases due to their steady state release, persistent therapeutic activity, and ability to bypass most ocular barriers. However, implants are considered invasive drug delivery technologies, especially those that are nonbiodegradable. Furthermore, in vitro characterization approaches, although useful, are limited in mimicking or truly representing the in vivo environment. This review focuses on long-acting drug delivery systems (LADDS), particularly implantable drug delivery systems (IDDS), their formulation, methods of characterization, and clinical application for the treatment of eye diseases.

Accuracy of a New Noninvasive Automatic Ocular Surface Analyzer for the Diagnosis of Dry Eye Disease-Two-Gate Design Using Healthy Controls

PURPOSE

The purpose of this study was to assess the diagnostic performance of measurements from a new noninvasive, automated ocular surface analyzer (IDRA) in the diagnosis of dry eye disease (DED).

METHODS

We prospectively identified patients with and without DED using best practice methods. Subsequently, all participants underwent IDRA analysis, consisting of 5 components: noninvasive tear film break-up time, tear meniscus height, lipid layer interferometry, eye blink quality, and infrared meibography. The manufacturer provides cutoff values for a pathologic result for each of these components. Using a stepwise augmentation multivariate logistic regression model, we identified the components with the strongest association for the presence of DED. For the 3 components with the strongest association (interferometry, tear meniscus, and infrared meibography), we calculated the probability of DED.

RESULTS

We enrolled 40 patients (80 eyes) with DED (mean age 60.5 years; women 78.3%) and 35 healthy subjects (70 eyes, mean age 31.1 years; women 21.7%). The IDRA had an area under the curve of 0.868 (95% confidence interval: 0.809-0.927) to detect DED. A normal (≥80) interferometry combined with a normal (>0.22) tear meniscus and a normal (≤40) infrared meibography was associated with an estimated probability of 18% for the presence of DED, whereas the estimated probability of DED was as high as 96% when all 3 findings were pathologic.

CONCLUSIONS

The results of IDRA showed a positive concordance with routine clinical diagnostic tests. The new analyzer is an easy-to-access diagnostic tool to rule out the presence of DED in the extramural setting and to guide a timely DED treatment.

Rheumatoid Arthritis Associated with Dry Eye Disease and Corneal Surface Damage: A Nationwide Matched Cohort Study

Rheumatoid arthritis is potentially connected to ocular disorders, such as corneal inflammation and lacrimal gland destruction. This study aimed to evaluate the risk of dry eye disease (DED) and corneal surface damage among patients with rheumatoid arthritis. In a nationwide cohort study, we utilized Taiwan’s National Health Insurance research database and conducted propensity score matching to compare the risks of DED and corneal surface damage between patients with and without rheumatoid arthritis. Proportional hazards regression analyses were used to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for the outcomes of interest. The matching procedure generated 33,398 matched pairs with 501,377 person-years of follow-up for analyses. The incidence of DED was 23.14 and 10.25 per 1000 person-years in patients with and without rheumatoid arthritis, respectively. After adjusting for covariates, rheumatoid arthritis was significantly associated with DED (aHR: 2.03, 95% CI: 1.93−2.13, p < 0.0001). The association was generally consistent across the subgroups of age, sex, use of systemic corticosteroids, and different comorbidity levels. In addition, patients with rheumatoid arthritis had a higher risk of corneal surface damage (aHR: 1.36, 95% CI: 1.21−1.51, p < 0.0001) compared to control subjects. Other independent factors for corneal surface damage were age and sleeping disorders. Rheumatoid arthritis was associated with an increased risk of DED and corneal surface damage. Ophthalmological surveillance is required to prevent vision-threatening complications in this susceptible population.

Association between dry eye disease and depression: An umbrella review

PURPOSE

This umbrella review aimed to summarize the available evidence on the association between dry eye disease and depression.

METHODS

We searched the Pubmed, Embase, and Cochrane databases using the search string "(Dry eye syndrome OR Keratoconjunctivitis sicca OR KCS OR Aqueous tear deficiency OR Sjogren syndrome) AND (depression OR depressive symptoms) AND (meta-analysis OR systematic review)" from inception to 20 July 2022. We considered all meta-analyses investigating the association between dry eye disease and depression.

RESULTS

After summarizing the included meta-analyses, it was concluded that dry eye disease is associated with depression. The symptoms of dry eye disease affect the daily lives of patients, thus affecting their mood. However, further evidence is required to confirm this association.

CONCLUSION

This finding highlights the importance of psychological support for patients with dry eye disease. Future clinical studies should investigate the mechanism underlying the association between dry eye disease and depression.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022320619.

Clinical association between trace elements of tear and dry eye metrics

Trace elements exposure is proposed to play a role in the pathogenesis of the systemic disease. Emerging studies have suggested that trace metal exposure may contribute to dry eye disease. Our study primarily aimed to investigate the association between trace metal exposure in tear samples and the presence of dry eye metrics in the shipyard industry. Overall, 84 eligible participants from the shipyard industry were included in this cross-sectional study. The parameters for identifying dry eye symptoms included O.S.D.I., SPEED, N.I.B.U.T., and ocular surface conditions, such as tear meniscus height, eye blinking, and meibomian gland area were performed by S.B.M. sistemi ocular surface analyzer. The concentration of tear trace elements was detected by inductively coupled plasma mass spectroscopy (ICP-MS). The association between tear trace elements and dry eye parameters was investigated using regression models. Participants in the exposure group had significantly higher levels of tear Pb than the control group. In the exposure group, tear Pb was significantly associated with increased SPEED and O.S.D.I. score with beta coefficients of 0.144 (95% CI 0.092, 0.197), 0.121 (95% CI 0.049, 0.194), respectively, and decreased lower and upper meibomian gland area with beta coefficients of - 0.158 (- 0.283, - 0.033) and - 0.228 (- 0.396, - 0.061), respectively. Tear trace elements exposure is considered to impact the appearance of dry eye metrics. Improving the occupational environment and monitoring the ocular surface health may benefit workers under exposure to trace elements.

A Review of Corneal Blindness: Causes and Management

Corneal blindness refers to a group of eye disorders that change the corneal transparency, causing corneal scarring and blindness. The leading causes of corneal blindness include infectious causes, i.e., due to bacteria, viruses, fungi, and protozoa. The most common predisposing factors are trauma, contact lens usage, or the use of steroid medications. The various other diseases included are trachoma, dry eye disease, keratoconus, ophthalmia neonatorum, and non-infectious uveitis. Various clinical modalities are used for treating corneal blindness, including organ transplantation. Organ donation is cumbersome as various ethical and other factors are involved. Hence the concept of eye banking was introduced to meet the increasing demand for donors of the cornea. The eye bank's role is harvesting, processing, and keeping a record of the cornea being transplanted and donated. Furthermore, various recent advancements have been made for lamellar keratoplasty surgeries, including bioengineered corneas to fulfil the need for the unavailability of donors for the cornea. Various specific health interventions have been implemented to reduce the prevalence of corneal blindness globally. For proper management of corneal blindness, we have three components that are needed to be taken care of: prevention of corneal blindness, appropriate treatment modalities, and providing adequate rehabilitation services to the patients. This review encompasses the main reasons for corneal blindness and the management and treatment modalities available for the patients. The terms cornea, corneal blindness, treatment, management, causes, and complications were used for the review article on PubMed.

Proteases and Their Potential Role as Biomarkers and Drug Targets in Dry Eye Disease and Ocular Surface Dysfunction

Dry eye disease (DED) is a multifactorial disorder that leads to ocular discomfort, visual disturbance, and tear film instability. DED is accompanied by an increase in tear osmolarity and ocular surface inflammation. The diagnosis and treatment of DED still present significant challenges. Therefore, novel biomarkers and treatments are of great interest. Proteases are present in different tissues on the ocular surface. In a healthy eye, proteases are highly regulated. However, dysregulation occurs in various pathologies, including DED. With this review, we provide an overview of the implications of different families of proteases in the development and severity of DED, along with studies involving protease inhibitors as potential therapeutic tools. Even though further research is needed, this review aims to give suggestions for identifying novel biomarkers and developing new protease inhibitors.

Characteristic of red eye related diseases of Han and Uygur population in Urumchi compared with Shanghai, China

AIM

To study the characteristics, relative distribution and to compare causes of red eye in ophthalmic clinics in Urumchi and Shanghai, China.

METHODS

Data on continuous cases of red-eye patients admitted to the Ophthalmology Center of Xinhua Hospital Affiliated to Shanghai Jiao Tong University and the First Affiliated Hospital of Xinjiang Medical University were collected between November 2018 and September 2019. Demographic data, the incidence of red eye and related disease distribution of all cases were obtained. The independent t-test method was used for age comparison, while the Chi-square test was used to compare classified data information.

RESULTS

The information on 335 and 415 patients with red eyes in Shanghai and Urumchi were collected, respectively. The main causes of red eye were conjunctival disease and dry eye. The age of female patients with red eyes was significantly higher than that of males, and the proportion of female patients with dry eyes was also higher. Red-eye-related diseases occurred more frequently in patients over 46 years old than in those under 18, and dry eye was more common with increasing age. The incidence of infectious conjunctivitis in Urumchi was significantly higher than that in Shanghai, and allergic conjunctivitis occurred more frequently in spring, summer, or autumn than in winter (all P<0.05).

CONCLUSION

Significant differences exist in the distribution of red-eye-related diseases in Urumchi and Shanghai regions of China, and distribution varies with age and season, the latter being an important feature of allergic conjunctivitis.

Hyaluronic Acid and Galacto-Xyloglucan Eyedrop Efficacy in Young-Adult Oral Contraceptive Users of Childbearing Age

To assess the efficacy of 0.4% hyaluronic acid and 0.2% galacto-xyloglucan for the subjective symptoms of dry eye disease and tear film invasive and noninvasive signs in 34 young-adult oral contraceptive users of childbearing age, a prospective, longitudinal, single-blind, clinical study was performed in a population of childbearing-age oral-contraceptive consumers. Subjective dry eye disease questionnaires, and invasive and noninvasive tear film assessments were reported before and after six weeks of hyaluronic acid with galacto-xyloglucan (HA-GX) treatment versus hyaluronic acid alone (HA). HA-GX treatment resulted in a greater decrease in the ocular surface disease index (17.01 ± 11.36 score points, p < 0.01) than the HA variation (11.61 ± 11.18 score points, p < 0.01). The standard patient evaluation of eye dryness also decreased more in the HA-GX group (4.06 ± 5.50 score points, p < 0.01) than in the HA alone group (0.70 ± 3.16, p = 0.21). Regarding noninvasive break-up time (NIBUT), the HA-GX group’s first NIBUT achieved an increase of 1.75 ± 1.16 s, p < 0.01, while the HA-alone group increased by only 0.54 ± 1.01 s, p < 0.01. The HA-GX group’s mean NIBUT reported an increase of 3.72 ± 5.69 s, p < 0.01; however, the HA-alone group achieved 2.19 ± 5.26 s, p = 0.05. Hyaluronic acid in combination with galacto-xyloglucan significantly decreased subjective dry eye disease symptoms and increased first and mean NIBUT compared to hyaluronic acid alone. Galacto-xyloglucan added efficacy in young-adult childbearing-age oral contraceptive users.

Oral isotretinoin for acne vulgaris side effects on the ocular surface: Hyaluronic acid and galacto-xyloglucan as treatment for dry eye disease signs and symptoms

The purpose was to assess the efficacy of 0.4% hyaluronic acid and 0.2% galacto-xyloglucan on the subjective symptoms of dry eye disease and invasive and non-invasive tear film signs in oral isotretinoin for acne vulgaris treatment. A prospective, longitudinal, single-blind, clinical study was performed in oral isotretinoin for the acne vulgaris consumer population. Subjective dry eye disease questionnaires and invasive and non-invasive tear film assessments were reported prior to and after 6 weeks of hyaluronic acid with galacto-xyloglucan (HA-GX) treatment vs. hyaluronic acid alone (HA). Participants in the HA-GX group reported a higher decrease in the ocular surface disease index (17.01 ± 11.36 score points) compared to the variation in participants in the HA group (11.61 ± 11.18 score points). Standard patient evaluation of eye dryness also decreased more in participants in the HA-GX group (4.06 ± 5.50 score points) than in participants who received HA alone (0.70 ± 3.16). Regarding non-invasive break-up time (NIBUT), participants in the HA-GX group first NIBUT achieved an increase of 1.75 ± 1.16 s while participants in the HA-alone group demonstrated an increase of only 0.54 ± 1.01 s. The HA-GX group mean NIBUT increased by of 3.72 ± 5.69 s; however, the value for the HA-alone group was 2.19 ± 5.26 s. Hyaluronic acid in combination with galacto-xyloglucan significantly decreased limbal and bulbar conjunctival redness classification and SPEED test outcomes. The inclusion of galacto-xyloglucan also increased BUT and mean NIBUT values compared to those obtained with hyaluronic acid alone.

Results from a Prospective, Open-Label, Phase 4 Pilot Study of Repository Corticotropin Injection for Moderate and Severe Dry Eye Disease

INTRODUCTION

There is a substantial unmet need for effective therapies to treat patients with refractory dry eye disease (DED). The goal of this open-label pilot study was to investigate the efficacy and safety of repository corticotropin injection (RCI; Acthar® Gel; Mallinckrodt Pharmaceuticals) in subjects with DED, most of whom did not experience adequate response to standard-of-care therapies.

METHODS

Adults with moderate or severe-acute DED received 80 U of subcutaneous RCI twice weekly for 12 weeks. Primary efficacy outcomes were improvements in corneal fluorescein staining of superficial punctate keratitis (SPK) lesions and Symptom Assessment in Dry Eye (SANDE) scores. Secondary outcomes included changes in Schirmer's test scores, conjunctival lissamine green staining, erythema, intraocular pressure (IOP), and best corrected visual acuity (BCVA). Adverse events (AEs) were assessed continuously throughout the study.

RESULTS

Fifteen subjects received at least 1 dose of RCI, and 12 subjects completed the study. Compared to baseline (day 1), significantly fewer fluorescein-stained SPK lesions were detected at day 14 (p = 0.0250) and day 84 (p = 0.0240) after RCI treatment. Mean SANDE scores progressively declined from 62.0 at baseline to 46.9 at day 84. Erythema (p = 0.0046), conjunctival lissamine green staining of SPK lesions (p = 0.0317), and IOP (p = 0.0052) were all significantly improved after 12 weeks of RCI therapy. Schirmer's test scores and BCVA showed no significant changes throughout the study. No ocular AEs or deaths occurred, and no new safety signals were identified for RCI.

CONCLUSIONS

These results suggest that RCI may be a safe and effective treatment for moderate and severe DED.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03287635.

Changing trends in ophthalmological emergencies during the COVID-19 pandemic

On March 11, 2020, the World Health Organization declared COVID-19—the infectious disease caused by SARS-CoV-2—a pandemic. Since then, the majority of countries—including Spain—have imposed strict restrictions in order to stop the spread of the virus and the collapse of the health systems. People’s health care–seeking behavior has exhibited a change, not only in those months when the COVID-19 control measures were strictest, but also in the months that followed. We aimed to examine how the trends in ophthalmological emergencies changed during the COVID-19 pandemic in one of the largest tertiary referral hospitals in Spain. To this end, data from all the patients that attended the ophthalmological emergency department during the pandemic period—March 2020 to February 2021—were retrospectively collected and compared with data from the previous year. Moreover, a comparison between April 2020—when the restrictions were most severe—and April 2019 was made. A total of 90,694 patients were included. As expected, there was a decrease in the number of consultations. There was also a decrease in the frequency of conjunctival pathology consultations. These changes may bring to light not only the use that people make of the emergency department, but also the new trends in ophthalmological conditions derived from the hygienic habits that the COVID-19 pandemic has established.

Abnormal Fractional Amplitude of Low Frequency Fluctuation Changes in Patients With Dry Eye Disease: A Functional Magnetic Resonance Imaging Study

Purpose

To investigate spontaneous brain activity in patients with dry eye (DE) and healthy control (HC) using the fractional amplitude of low frequency fluctuation (fALFF) technique with the aim of elucidating the relationship between the clinical symptoms of DE and changes in brain function.

Material and Methods

A total of 28 patients with DE and 28 matched healthy volunteers (10 males and 18 females in each group) were enrolled. Resting-state functional magnetic resonance imaging scans were performed in both groups. Then all subjects were required to complete a comprehensive Hospital Anxiety and Depression Scale (HADS). Receiver operating characteristic (ROC) curve analysis was used to evaluate the differences in fALFF values between the two groups and their diagnostic value. Linear correlations between HADS and fALFF values in different brain regions of DE patients were analyzed using the Pearson correlation coefficient.

Results

Patients with DE had significantly higher fALFF values in the left calcarine sulcus (CS) than the HC group, while fALFF values in the bilateral middle frontal gyrus (MFG) and right MFG/right inferior frontal gyrus (IFG) were significantly lower in DE patients than in HC group. fALFF values had a high diagnostic value for differentiating patients with DE from the HC group (P &lt; 0.001). Right MFG and right MFG/IFG were significantly correlated with HADS values.

Conclusion

Our study found that DE mainly involved functional disorders in the brain areas of the left CS, bilateral MFG and right MFG/right IFG, which helped us to find possible clinical features of DE disease and reflected the potential pathological mechanism of DE.

Efficacy of hyaluronic acid 0.3%, cyanocobalamin, electrolytes, and P-Plus in menopause patients with moderate dry eye disease

Purpose

To study the treatment efficacy of hyaluronic acid 0.3%, cyanocobalamin (vitamin B12), electrolytes, and P-Plus in menopausal patients with moderate dry eye disease.

Methods

Thirty female patients of mean age 53.06 ± 5.20 years (45–65) were enrolled in this prospective longitudinal study. Meibomian gland loss assessment was determined using a scale with four levels. The Ocular Surface Disease Index (OSDI) questionnaire, phenol red thread (PRT) test, and tear film break-up time (TFBUT) were also completed by the patients. Tear eye drops were formulated with 0.3 g of sodium hyaluronate, P-Plus ™, vitamin B12, sodium chloride, potassium chloride, calcium chloride, magnesium chloride, and SCO® (stabilized complex oxychloride). After 30 days, the patients were re-evaluated.

Results

The mean meibomian gland loss percentage was 37.97 ± 19.02 % (7.20 to 88.30%). Before treatment, the OSDI was 22.53 ± 14.03 score points (6.25 to 77.08). Posterior OSDI decreased to 16.26 ± 13.69 score points (0.00 to 70.83) (W = 58.00, P < 0.01). Before treatment, PRT was 10.31 ± 4.48 mm (4.00 to 21.00). Posterior PRT increased to 15.41 ± 6.27 mm (4.00 to 21.00) (W = 1520.50, P < 0.01). Before treatment, TFBUT was 6.23 ± 1.75 s (3.00 to 9.00). The posterior TFBUT increased to 8.10 ± 2.06 s (4.00 to 14.00) (W= 1382.50, P < 0.01).

Conclusion

The hyaluronic acid 0.3% and vitamin B12 eye drops effectively decreased dry eye symptoms in menopausal women and improved tear stability and volume.

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

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