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

Visual Functioning and Mental Health in the Digital Age

Background/Objectives: Considering the omnipresence of digital devices in every aspect of our lives, and from an increasingly younger age, digital eye strain (DES) and dry eye disease (DED) have become a global concern. The main objective of this paper is to conduct a systematic review of the literature on the relationship between digital screen use and ocular surface health, as well as the potential negative impact of impaired visual functioning on certain aspects of mental health and daily performance. Methods: Using the PRISMA method, the screening and study selection process resulted in the inclusion of 15 papers published in the electronic databases PubMed and WoS. Results: The findings highlight the prolonged use of digital devices and the concerning prevalence of DED or DES symptoms across different populations. A significant relationship was found between DED and DES symptoms and mental health outcomes, including depression, anxiety, and stress. Furthermore, higher frequency and severity of DED or DES symptoms was associated with reduced sleep quality and difficulties in certain aspects of daily functioning. Conclusions: Given the ongoing exposure to digital devices and increasing prevalence of DED and DES symptoms across all age groups, there is a need to design interventions and programs focused on preserving ocular surface health and improving subjective well-being. The multifaceted impact these symptoms have on physical and mental health, as well as daily functioning, requires a holistic approach, integrating ergonomic interventions, digital hygiene, and mental health support.

Insights into the Correlation and Immune Crosstalk Between COVID-19 and Sjögren's Syndrome Keratoconjunctivitis Sicca via Weighted Gene Coexpression Network Analysis and Machine Learning

Background: Although autoimmune complications of COVID-19 have aroused concerns, there is no consensus on its ocular complications. Sjögren's syndrome is an autoimmune disease accompanied by the ocular abnormality keratoconjunctivitis sicca (SS-KCS), which may be influenced by COVID-19. Thereby, we explored the possible interaction between COVID-19 and SS-KCS, and we aimed to elucidate the potential correlated mechanism. Methods: Differentially expressed genes (DEGs) in COVID-19 and SS-KCS transcriptome data obtained from the gene expression omnibus database were identified, and COVID-19-related genes were screened using weighted gene coexpression network analysis. Common genes were verified using four machine-learning diagnostic predictors. The clinical relationship between the two common hub genes of COVID-19 was analyzed. Finally, the immune cell types infiltrating the microenvironment in the COVID-19 dataset were analyzed using CIBERSORT, and the interrelation between key genes and differentially infiltrating immune cells was verified via Pearson correlation. Results: Ten potential primary hub mRNAs were screened by intersecting the COVID-19 DEGs, SS-KCS DEGs, and WGCNA genes. After a multifaceted evaluation using four mainstream machine-learning diagnostic predictors, the most accurate and sensitive random forest model identified CR1 and TAP2 as the common hub genes of COVID-19 and SS-KCS. Together with the clinical information on COVID-19, the expression of CR1 and TAP2 was significantly correlated with the status and severity of COVID-19. CR1 and TAP2 were significantly positively correlated with M0 and M2 macrophages, neutrophils, and CD4+ memory resting T cells and negatively correlated with activated NK cells, monocytes, and CD8+ T cells. Conclusions: We validated the hub genes associated with both COVID-19 and SS-KCS, and we investigated the immune mechanisms underlying their interaction, which may help in the early prediction, identification, diagnosis, and management of SARS-CoV-2 infection-related SS-KCS syndrome or many other immune-related complications in the long COVID period.

Multidimensional immunotherapy for dry eye disease: current status and future directions

Dry Eye Disease (DED) is a multifactorial condition driven by tear film hyperosmolarity, immune dysregulation, and neuro-immune interactions. The immune system plays a central role in its pathogenesis, influencing both inflammation and ocular surface damage. While traditional immunotherapies like anti-inflammatory agents and immunosuppressants offer symptom relief, their long-term use is limited by side effects. This review focuses on emerging immunotherapies, including biologics, stem cell therapy, gene therapy, nanotechnology, and exosome-based treatments, all of which hold promise in modulating immune responses and promoting tissue repair. The relationship between the ocular microbiome and DED is also explored, with an emphasis on personalized immunotherapy. Key challenges for future research include identifying novel therapeutic targets, optimizing clinical translation, and evaluating the long-term efficacy of these innovative treatments.

Prevalence of dry eye disease symptoms, associated factors and impact on quality of life among medical students during the pandemic

This cross-sectional study aimed to evaluate the prevalence of dry eye disease (DED) symptoms, their associated factors, and the impact on quality of life (QOL) and mental health among medical students during the COVID-19 pandemic using online surveys. Participants completed questionnaires covering demography, medical history, and personal data. The Thai version of the Dry Eye-related Quality-of-Life Score (DEQS-Th) was used for DED screening. The QOL and mental health challenges (support, coping, stress, and depression) were evaluated by the EuroQoL-5 dimensions-5 levels (EQ-5D-5L) and Thymometer questionnaires. A total of 449 participants were analyzed, with a mean age of 21.8 years and 61.5% female. The prevalence of DED symptoms was 60.4% (95%CI 55.7-64.8). The DEQS-Th score, the EQ-5D-5L score, and all aspects of mental health challenges were significantly worse in DED participants compared to non-DED participants. Associated factors for DED symptoms included preexisting DED (p = 0.001), refractive errors (p = 0.007), allergic conjunctivitis (p = 0.001), artificial tears use (p < 0.001), and decreased EQ-5D-5L score (p < 0.001). This study highlighted the high prevalence of DED symptoms among medical students during the pandemic and its negative impact on QoL and mental health. Notably, female gender, contact lens wear, screen time, and mask-wearing duration were not associated with DED symptoms.

A specific chiral HPLC method for lifitegrast and determination of enantiomeric impurity in drug substance, ophthalmic product and stressed samples

Lifitegrast is a lymphocyte function-associated antigen-1 (LFA-1) antagonist used to treat the indications and symptoms associated with dry eye disease (DED), one of the most common ocular surface diseases. Lifitegrast has a chiral center, and the S-enantiomer (S-Lif) is responsible for the therapeutic effects, while the R-enantiomer (R-Lif) lacks efficacy in the treatment of DED. Lifitegrast ophthalmic solution containing 5% lifitegrast was approved by the United States Food and Drug Administration (FDA) in July 2016 for the treatment of DED in patients 17 years of age and older. The objective of this study was to develop a chiral HPLC method for the determination of the enantiomeric impurity of lifitegrast in the drug substance and in the ophthalmic product. In addition, we aimed to investigate the effect of stress and stability conditions on the enantiomeric purity of lifitegrast in both drug substance and ophthalmic solution. During the method development studies, four known lifitegrast impurities (Lif. Imp. A-D) and stressed lifitegrast samples were injected to ensure the specificity of the developed method. The enantiomers of lifitegrast are well separated with a resolution of higher than 4.0. They are also well separated from the peaks of the diluent, impurities, and the placebo used to prepare the ophthalmic solution without interference in 20 min. Chiral separation was achieved using a Chiralpak AD-H column (250 × 4.6 mm, 5.0 μm) at 40 °C with a mobile phase consisting of a mixture of n-hexane, 2-propanol, and formic acid (500:500:2, v/v/v) at a flow rate of 1.0 mL/min and a detection wavelength of 260 nm. Methanol was used as the diluent, and the drug substance solution was found to be stable for 48 h at 15 °C. The optimized chiral HPLC method for lifitegrast was validated according to ICH Q2, and the calibration curves showed excellent linearity for R-Lif (0.0369 - 1.816 µg/mL). This is the first stability-indicating, specific / selective, sensitive, linear, precise, accurate, and robust chiral HPLC method for the determination of R-Lif in S-Lif. The amount of enantiomeric impurity R-Lif in S-Lif increased under all stress and photostability test conditions without exceeding the acceptable impurity limit, with the most significant increase observed at elevated temperatures (105 °C) for both the drug substance in powder form and the ophthalmic drug solution.

Research trends of worldwide ophthalmologic randomized controlled trials in the 21st century: A bibliometric study

Background

Randomized controlled trials (RCTs) are often considered the gold standard and the cornerstone for clinical practice. However, bibliometric studies on worldwide RCTs of ophthalmology published in the 21st century have not been reported in detail yet. This study aims to perform a bibliometric study and visualization analysis of worldwide ophthalmologic RCTs in the 21st century.

Methods

Global ophthalmologic RCTs from 2000 to 2022 were searched in the Web of Science Core Collection. The number of publications, country/region, institution, author, journal, and research hotspots of RCTs were analyzed using HistCite, VOSviewer, CiteSpace, and Excel software.

Results

2366 institutions and 90 journals from 83 countries/regions participated in the publication of 1769 global ophthalmologic RCTs, with the United States leading in the number of volumes and research field, and the Moorfields Eye Hospital contributing to the most publications. Ophthalmology received the greatest number of publications and co-citations. Jeffrey S. Heier owned the most publications and Jost B. Jonas owned the most co-citations. The knowledge foundations of global ophthalmologic RCTs were mainly retinopathy, glaucoma, dry eye disease (DED), and cataracts, and anti-vascular endothelial growth factor (VEGF) therapy (ranibizumab), topical ocular hypotensive medication, laser trabeculoplasty. Anti-VEGF therapy for age-related macular degeneration (AMD), DME (diabetic macular edema), and DED, the use of new diagnostic tools, and myopia were the hottest research highlights. Anti-VEGF therapy, prompt laser, triamcinolone, and verteporfin photodynamic therapy for AMD, DME, and CNV (choroidal neovascularization), DED, myopia, and open-angle glaucoma were the research hotspots with the longest duration. The future research hotspots might be DED and the prevention and control of myopia.

Conclusions

Overall, the number of global ophthalmologic RCTs in the 21st century was keeping growing, there was an imbalance between the regions and institutions, and more efforts are required to raise the quantity, quality, and global impact of high-quality clinical evidence in developing countries/regions.

Extending the use of biologics to mucous membranes by attachment of a binding domain

Biologics are almost exclusively administered systemically, but localized delivery is preferable as it minimizes off-target exposure and allows more aggressive treatments. Topical application of biologics to epithelia is generally ineffective because most are covered with fluids and biologics are washed out too quickly to have significant therapeutic effects. Here we explore the idea that attaching a binding domain can serve as an "anchor" to extend the residency time of biologics on wet epithelia, allowing their effective use even with infrequent applications. We use topical application to the ocular surface as a challenging test since foreign substances are washed out especially efficiently by tear flow and blinking. Our results demonstrate that conjugation of antibodies to wheat germ agglutinin, which binds GlcNAc and sialic acid that are ubiquitously present in tissues, increases their half-life 350-fold upon application to the ocular surface in a mouse model of dry eye, a common and onerous disease in humans. Importantly, antibodies to IL-17A, IL-23, and IL-1β conjugated to the agglutinin reduces manifestations of dry eye, even when applied just once daily. In contrast, unconjugated antibodies are ineffective. Attaching an anchor to biologics is a simple means to overcome washout and to extend their therapeutic use.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

A Pilot Study of a Panel of Ocular Inflammation Biomarkers in Patients with Primary Sjögren’s Syndrome

Ocular diseases have a strong impact on individuals, the effects of which extend from milder visual impairment to blindness. Due to this and to their prevalence, these conditions constitute important health, social and economic challenges. Thus, improvements in their early detection and diagnosis will help dampen the impact of these conditions, both on patients and on healthcare systems alike. In this sense, identifying tear biomarkers could establish better non-invasive approaches to diagnose these diseases and to monitor responses to therapy. With this in mind, we developed a solid phase capture assay, based on antibody microarrays, to quantify S100A6, MMP-9 and CST4 in human tear samples, and we used these arrays to study tear samples from healthy controls and patients with Sjögren’s Syndrome, at times concomitant with rheumatoid arthritis. Our results point out that the detection of S100A6 in tear samples seems to be positively correlated to rheumatoid arthritis, consistent with the systemic nature of this autoinflammatory pathology. Thus, we provide evidence that antibody microarrays may potentially help diagnose certain pathologies, possibly paving the way for significant improvements in the future care of these patients.

Face mask use and effects on the ocular surface health: A comprehensive review

In the COVID-19 period, face masks increased exponentially. Several studies suggest that the rise in ocular discomfort symptoms during the pandemic is mostly part of dry eye disease and that these are due to the effect of face masks, resulting in the newly described term MADE, for "mask-associated dry eye". The most commonly proposed mechanism states that wearing a face mask creates an unnatural upward airflow towards the ocular surface during expiration, although the increased temperature, humidity and levels of carbon dioxide of the exhaled air, stress, increased use of video display terminals, as well as changes in the ocular microbiota may contribute. Evidence supports that the use of face masks causes an increase in dry eye disease symptoms, a decreased tear break-up time, corneal epithelial trauma, periocular temperature changes and inflammatory markers secretion. Given that the use of masks may be frequent in some settings in the near future, it is important to establish its effects and consequences on the ocular surface.

Relationship Between Screen Time and Dry Eye Symptoms During the COVID-19 Pandemic in the Pediatric Population of the Western Region of Saudi Arabia

Objective To measure the prevalence of dry eye disease (DED) and study the relationship between screen time and dry eye symptoms in the pediatric population during the coronavirus disease 2019 (COVID-19) pandemic using the Ocular Surface Disease Index (OSDI) questionnaire. Methods In this descriptive, observational, cross-sectional study, our survey included the pediatric population, ages 1 to 18 years, of both genders, who attended outpatient clinics of two main hospitals in Jeddah, Saudi Arabia. Collected data included age, gender, dry eye symptoms, and common DED risk factors, followed by the Ocular Surface Disease Index (OSDI) questionnaire, which consists of 12 items graded on a five-point scale (0 = never to 4 = all the time). Results A total of 329 pediatric participants were included, with more than half of the participants (56.1%) males and 58.5% aged 12-18 years. The most frequently reported symptoms (reported as often or always) were decreased vision (23.0%) and itchy eyes (22.1%). Environmental factors have an effect on developing DED symptoms, as some participants (21.8%) have reported being uncomfortable in windy weather and 15.8% have reported this in places with air conditioners. Based on the OSDI diagnostic criteria, 250 (76.1%) participants had DED. Furthermore, in terms of severity, 44 (13.3%) participants had mild DED, 62 (18.8%) participants had moderate DED, and 145 (43.9%) participants had severe DED. We found that prolonged exposure to mobile screens for two to three hours or four hours or more was associated with a higher DED incidence compared to those exposed for shorter periods. Older age categories were more likely to experience DED (80.8% and 78.2% in age categories 12-18 and 7-12, respectively, versus 57.6% in the youngest age category (p = 0.001)). Additionally, DED was independently associated with participants with a previous history of eyeglasses prescription and those experiencing dry eyes while using electronic devices. Conclusion Since many children use electronic devices for education and entertainment, we found that symptoms of DED due to prolonged screen time have increased among the pediatric population during the COVID-19 pandemic. Therefore, awareness efforts should be directed to reduce the rate of controllable risk factors like personal computer use. In addition, educational campaigns are warranted to provide all possible preventive measures against DED, especially to children with uncontrollable risk factors for developing DED.

Ocular Surface Changes Associated with Face Masks in Healthcare Personnel during COVID-19 Pandemic

The aim of this study was to investigate ocular surface changes associated with face mask (FMs) use of healthcare personnel during the COVID-19 pandemic. We prospectively evaluated 200 eyes of 100 individuals during working hours and 40 eyes of 20 individuals during their rest days as a control group. Dry eye symptoms were assessed with the Ocular Surface Disease Index (OSDI) and McMonnies questionnaire. The clinical investigation included the best corrected visual acuity (BCVA), corneal fluorescein staining (FS), break-up time (BUT), and Schirmer test I before and after a 7-h work shift with a continuative use of surgical or N95 masks. The control group was evaluated similarly twice a day, at 8:00 a.m. and at 3:00 p.m.. In the study group, BCVA, FS, BUT, and Schirmer test were investigated and there was a significant negative variation at the end of the shift. On the contrary, the control group did not show significant variations of any clinical feature. Furthermore, no significant changes in clinical parameters were observed during the use of surgical or N95 masks. In conclusion, FMs continuative use resulted in daily ocular surface modifications specifically in healthcare personnel.

Provocation of dry eye disease symptoms during COVID-19 lockdown

To assess the impact of COVID-19 lockdown measures on dry-eye symptoms in a community-based population, a cross-sectional study was conducted during the first wave of the COVID-19 outbreak in Thailand. An online survey was distributed via social media between June and July 2020. The questionnaire elicited information on demographics, dry-eye symptoms, use of visual display terminals, and mental health status. There were 535 respondents. Thirty-seven percent reported having been diagnosed with dry-eye disease (DED). During the lockdown, the mean dry-eye symptom score (DESS) of overall participants dropped significantly from 81.6 ± 15.9 to 79.8 ± 17.4 (P < 0.001). The mean, daily, visual display terminal (VDT) usage increased from 10.55 ± 5.16 to 13.08 ± 5.65 h (P < 0.001). A negative correlation between age and VDT usage was observed in both the normal and lockdown situations. One-quarter of all participants had an abnormal mental health status. The female gender (OR 1.86; 95% CI 1.14–3.04) and increased VDT usage during the lockdown (OR 5.68; 95% CI 3.49–9.23) were independently associated with worsening dry-eye symptoms. The lockdown measures abruptly altered the behaviors and lifestyles of the overall population. Excessive exposure to VDTs were associated with deteriorated dry-eye symptoms, and it possibly contributed to the increased DED incidence in the surveyed population.