The impact of dry eye disease on visual performance while driving

Real Life Impact of Dry Eye Disease

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

Binocular dynamic visual acuity in dry eye disease patients

Purpose

To investigate binocular dynamic visual acuity (DVA) for patients with dry eye disease (DED).

Methods

The prospective study included DED patients. The binocular DVA at 40 and 80 degrees per second (dps), Ocular Surface Disease Index (OSDI), tear meniscus height (TMH), tear film break-up time first (TBUTF), corneal fluorescein staining (CFS), eyelid margin abnormalities and meibomian gland (MG) abnormalities morphology and function were evaluated. A deep learning model was applied to quantify the MG area proportion. The correlation between DVA and DED parameters was analyzed.

Results

A total of 73 DED patients were enrolled. The age, OSDI, CFS, MG expressibility, secretion quality, and eyelid margin abnormalities were significantly positively correlated with the DVA for 40 and 80 dps (all P < 0.05). The MG area proportion in the upper eyelid was negatively correlated with DVA at 40 dps (R = −0.293, P < 0.001) and at 80 dps (R = −0.304, P < 0.001). Subgroup analysis by MG grade demonstrated that the DVA of patients with severe MG dropout (<25% of the total area) was significantly worse than other mild and moderate groups, both in 40 and 80 dps (all P < 0.05). The patients with CFS showed worse 40 (P < 0.001) and 80 dps (P < 0.001) DVA than the patients without CFS.

Conclusion

Binocular DVA is significantly associated with DED symptoms and signs. The DED patients with CFS and severe MG dropout and dysfunction have worse DVA.

Understanding and Optimizing Ocular Biometry for Cataract Surgery in Dry Eye Disease: A Review

PURPOSE

To understand the impact of dry eye disease (DED) on the components of ocular biometry and ways to optimize the visual outcomes of cataract surgery in eyes with DED.

METHODOLOGY

A thorough literature review of the components pertaining to this review was undertaken using the databases, PubMed (from the year 2000), MEDLINE, CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials. com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). The keywords used for the search included "cataract surgery" or "phacoemulsification" combined with "dry eye", "dry eye disease","biometry", "keratometry".

RESULTS

Publications considered for this review included meta-analysis, systematic reviews, case-control and cohort studies, case series, and laboratory-based studies. Published articles reporting tear film alteration in DED, its impact on the quality of vision and optical aberrations, the effect of topical medications on keratometry variations, and reports on optimizing the ocular surface before cataract surgery were included.

CONCLUSIONS

DED is a common entity seen in patients presenting to routine cataract clinics and is known to impact the accuracy, reliability, and repeatability of ocular biometry and IOL power calculations in them. This review intends to emphasize the preoperative screening for the presence of DED, initiation of appropriate medical management for optimization of the ocular surface before cataract surgery, and recommendations for performing biometry. The algorithmic approach proposed will help the general ophthalmologists in routine practice to provide quality care and acceptable visual outcomes in patients with pre-existing DED.

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.

Psychosocial Impact of Demodex Blepharitis

Purpose

To evaluate the impact of Demodex blepharitis on patients’ daily activities and quality of life.

Patients and Methods

In this multicenter, observational, prospective, IRB-approved study, 311 Demodex blepharitis patients aged ≥18 years were included. Demodex blepharitis was diagnosed based on the presence of ≥1.0 mite per lash (upper and lower eyelids combined), >10 collarettes on the upper lashes, and at least mild lid margin erythema of the upper eyelid in at least one eye. All patients were asked to complete a questionnaire about their symptoms, daily activities, quality of life, and management approaches, and descriptive statistics were used to analyze the responses.

Results

More than half the patients had been experiencing symptoms of blepharitis for ≥4 years. The three most frequent and bothersome symptoms experienced by patients were dry eyes, itchiness, and irritation. Nearly half the patients (47%) responded that they were conscious of their eyes all day, and 23% said that they were constantly worrying about their eyes. Other activities that were negatively affected included difficulty driving at night (47%), additional time needed for daily hygiene routine (30%), and difficulty in wearing eye make-up (in 34% of females). While all subjects had objective signs of Demodex blepharitis confirmed by an eye care provider, 58% said they had never previously been diagnosed with blepharitis. The most commonly used management approaches for Demodex blepharitis were artificial tears (47%), warm compresses (32%), and lid wipes (14%).

Conclusion

Demodex blepharitis has a significant negative impact on daily activities and the mental and physical well-being of afflicted patients.

Differentiating primary dry eye disease from ocular neuropathic pain: implications for symptom management

CLINICAL RELEVANCE

Eyecare practitioners' management of ocular surface disease is essential in managing increasing dry eye disease (DED) presentations including ocular neuropathic pain (ONP). Topical Proxymetacaine offers a simple, readily available and practical method of detecting ONP in practice and can be used to differentiate ONP from DED by eyecare practitioners, when accompanied with an anterior segment examination.

BACKGROUND

Differentiating DED from ONP presents a significant opportunity to eyecare providers, allowing appropriate treatment choices for more adequate symptom control, greater patient satisfaction, and reduced emergent re-presentations. This study aims to differentiate patients presenting with DED symptoms into DED or ONP using a simple diagnostic tool, which can be used in practice to allocate appropriate treatment options for the patient's respective condition. A comparison of the prevalence of presentations of ONP presenting with DED symptoms in hospital ophthalmology settings and in optometric primary care settings will also be made.

METHODS

Patients with symptoms of DED were opportunistically recruited as they presented to ophthalmology outpatient clinics and primary care optometric services. Patients were then categorised as DED, ONP, or mixed DED/ONP based on their subjective response 30 seconds post-Proxymetacaine Hydrochloride 2% instillation.

RESULTS

Twenty-one patients were recruited, including 12 patients from ophthalmologic outpatient clinics and nine patients from primary care optometric services. Twelve patients were identified to have primary DED, while nine patients were identified to have ONP. 43% of patients presenting with DED symptoms had features of neuropathic pain in ophthalmologic outpatient presentations compared to 44% of patients in primary care optometric services.

CONCLUSION

Categorising DED and ONP patients by their response to Proxymetacaine can be used as a simple diagnostic tool in guiding future patient management and can be indicative of their potential response to topical therapies. The use of topical Proxymetacaine and the resultant change in ocular pain score can facilitate selection of patients who may benefit from centrally acting neuropathic pain agents over topical ocular therapy.

Refractive errors among commercial drivers

Purpose

To determine the pattern of refractive error among commercial drivers in north India.

Methods

Descriptive study with convenient sampling conducted among commercial drivers of north India.

Results

A total of 213 (75.8%) heavy-vehicle and 68 (24.2%) light-vehicle drivers were screened for eye diseases. Refractive error for distance was reported in 44 (15.7%; 95% CI: 11.6-20.4) drivers. Hyperopia was reported in 23 (8.2%; 95% CI: 5.2-12) drivers, followed by myopia in 15 (5.3%; 95% CI: 3-8.6) drivers and astigmatism in six (2.1%; 95% CI: 0.7-4.5) drivers. Presbyopia was reported in 157 (55.8%) drivers. Dry eye was reported in 70 (24.9%), stereo deficiency in 77 (27.4%), and color vision deficiency in 11 (3.9%) drivers. Three drivers were diagnosed with cataract, and two were referred for retina evaluation.

Conclusion

Hyperopia in both eyes was the most common refractive error. Dry eye disease and color vision deficiency were also reported. Most of the drivers were not using spectacles for refractive error correction. Due to their mobile nature, drivers with cataract and retina diseases did not turn up for follow-up.

Differences of Anxiety and Depression in Dry Eye Disease Patients According to Age Groups

This study aimed to investigate the association between dry eye disease (DED) and DED-related anxiety and depression tendencies, as well as the risk factors for anxiety and depression in patients with DED of different age groups. This was a cross-sectional study involving 160 patients with DED and 80 healthy individuals aged 20-65 years. All participants completed the investigation of the demographic characteristics, the Hospital Anxiety Depression Scale (HADS), the Ocular Surface Disease Index (OSDI) questionnaire, the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and underwent objective clinical eye examinations. In patients aged 20-40 years, anxiety and depression scores were correlated with OSDI, sleep disorders, and Best Corrected Visual Acuity (BCVA). In patients with DED aged 41-65 years, anxiety scores were correlated with sleep disorders, the level of DED impact on life and work, and the severity of DED. Depression scores were correlated with sleep disorders and the severity of DED. The results indicated that the tendency for anxiety and depression was closely associated with DED and sleep disorders. Moreover, the factors affecting anxiety and depression in patients varied with age.

Dry eye disease and psychiatric disorders: A systematic review and meta-analysis

The association between dry eye disease (DED) and psychiatric conditions is a highly researched topic. This work reviews the literature on this relationship, examining the prevalence and correlations of depression and anxiety with dry eye signs and symptoms. A comprehensive literature search of MEDLINE, EMBASE, PsycINFO, and gray literature was conducted, with keywords for dry eye and mood disorders, depression, anxiety, and suicide. Eligible studies underwent quality assessment using the Newcastle-Ottawa Scale. Meta-analysis was performed using STATA 15.0. Fixed- and random-effects models were computed based on the presence of heterogeneity. Thirty-two studies were included, with 31 reporting on depression and 19 on anxiety. Meta-analysis results found a depression prevalence of 40% (CI: [0.29, 0.52]) in DED patients, with 1.81 times higher odds of prevalence compared to controls (CI: [1.61, 2.02]). Prevalence of anxiety was 39% (CI: [0.15, 0.64]), with 2.32 times higher odds of prevalence compared to controls (CI: [1.67, 3.23]). Depression scores were significantly higher in patients with DED in all studies. Anxiety scores were significantly higher in DED patients in studies using all scales except the Hospital Anxiety and Depression Scale-Anxiety Subscale. DED symptom scores were significantly associated with depression (ES = 0.43; CI: [0.31, 0.55]) and anxiety (ES = 0.41; CI: [0.32, 0.50]) scores. In conclusion, depression and anxiety are more prevalent and severe in DED patients and are correlated with dry eye symptoms but not signs. These findings highlight the interrelationship between these disorders and have important implications for providing appropriate care to these patients.

Change patterns in the corneal sub-basal nerve and corneal aberrations in patients with dry eye disease: An artificial intelligence analysis

We aimed to investigate the change patterns in corneal sub-basal nerve morphology and corneal intrinsic aberrations in dry eye disease (DED). Our study included 229 eyes of 155 patients with DED and 40 eyes of 20 healthy control. We used the Oculus keratograph and the ocular surface disease index questionnaire to assess their signs and symptoms. In vivo confocal microscopy was used to observe the corneal sub-basal nerves, corneal endothelial cells, and Langerhans cells (LCs). An artificial intelligence (AI) technique run by the deep learning model generated the sub-basal nerve fibre parameters. Furthermore, we used the Pentacam HR system to measure the corneal intrinsic aberrations and corneal surface regularity indices. DED patients more frequently had increased anterior and total corneal aberrations than controls (P < 0.05). In addition, DED had decreased average density and maximum length of corneal nerve. (Both P < 0.01) The LC number was significantly correlated with maximum length (CC = -0.19, P = 0.01) of the sub-basal nerve fibre. Furthermore, the corneal nerve average density was negatively correlated with IHD, and anterior, posterior, and total corneal aberrations (All P < 0.05) especially the higher-order aberrations. Significant correlations were seen between corneal nerve morphology changes, analysed by AI and corneal intrinsic aberrations, particularly higher-order aberrations.

A Systematic Review on the Association Between Tear Film Metrics and Higher Order Aberrations in Dry Eye Disease and Treatment

We systematically reviewed published research on dry eye disease and its association with higher order aberrations (HOAs). The purpose of this review was to first determine if an association between tear film metrics and HOAs exists and second to determine if the treatment of dry eyes can improve tear film metrics and HOAs together. A search was conducted in Entrez PubMed on 25 April 2021 using the keywords “higher order aberrations” and “dry eye”. The initial search yielded 61 articles. After publications were restricted to only original articles measuring HOA outcomes in patients with dry eye, the final yield was 27 relevant articles. Of these 27 papers, 12 directly looked at associations and correlations between dry eyes and HOA parameters. The remaining 15 studies looked at dry eye interventions and HOA outcomes and parameters. There is clear evidence demonstrating that dry eyes and HOAs have an association, and that the tear film is one of the most important factors in this relationship. There is also a direct correlation between tear film metrics and HOAs. Improvements in HOAs with dry eye interventions provide further evidence to support the intricate relationship between the two. Despite the clear association between HOAs and dry eye disease, further research is still required in the realm of clinical application as dry eye interventions vary depending on many factors, including patient severity and eye drop viscosity.

Advances in the Noninvasive Diagnosis of Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease that represents one of the most common ophthalmologic conditions encountered in everyday clinical practice. Traditional diagnostic tests for DED, such as subjective questionnaires, tear film break-up time and the Schirmer test, are often associated with poor reproducibility and reliability, which make the diagnosis, follow-up, and management of the disease challenging. New advances in imaging technologies enable objective and reproducible measurements of DED parameters, thus making the diagnosis a multimodal imaging-based process. The aim of this review is to summarize all the current and emerging diagnostic tools available for the diagnosis and monitoring of DED, such as non-invasive tear breakup time, thermography, anterior segment optical coherence tomography, meibography, interferometry, in vivo confocal microscopy, and optical quality assessment. Although there is not a gold standard imaging technique, new multi-imaging-integrated devices are precious instruments to help clinicians to better cope with the diagnostic complexity of DED.

The vision-related burden of dry eye

PURPOSE

To investigate the relationship between dry eye disease (DED) and vision-related quality of life (VR-QoL) at population level.

METHODS

DED and VR-QoL were assessed in 89,022 participants (18-96 years, 59% female) from the Dutch population-based Lifelines cohort using the Women's Health study (WHS) and Visual function 25 (VFQ25) questionnaires. The relationship between DED and compromised VR-QoL was assessed with logistic regression, corrected for age, sex, BMI, income, education, smoking, and 55 comorbidities.

RESULTS

9.1% of participants had DED. The participants with DED had higher risk of compromised average of ten domains of VR-QoL (OR 3.12 (95% CI 2.98-3.27) corrected for age, sex, BMI, income, smoking, and 55 comorbidities). Increasing symptom frequency was highly associated with decreasing VR-QoL (P < 0.0005). In all VR-QoL domains, including measures of daily visual function and emotional well-being, DED was clearly associated with compromised VR-QoL. Compared to macular degeneration, glaucoma, retinal detachment, and allergic conjunctivitis, DED presented similar or higher risks for compromised score on all VR-QoL domains. The population-attributable fraction of DED for compromised general vision exceeded that of other eye diseases investigated, especially in the younger age groups.

CONCLUSION

DED is associated with reductions in all domains of VR-QoL, also after correction for associated comorbidities. We found that DED imposes an extensive population burden regarding compromised VR-QoL due to its high prevalence and substantial impact on VR-QoL, higher than that for other common vision-affecting eye disorders. Our results emphasize the importance of recognizing DED as a serious disorder from both patient and public health perspectives.

Assessment of Ocular Surface Disease in Glaucoma Patients in Ghana

PRECIS

Dry eye disease (DED) observed in this study is associated with ocular surface abnormalities as shown by specific dry eye tests. Changes in tear quality may be responsible for dry eye symptoms among the participants.

PURPOSE

This study sought to evaluate DED in glaucoma patients in Ghana.

MATERIALS AND METHODS

This was a hospital-based descriptive cross-sectional study involving glaucoma patients on topical glaucoma treatment for at least 6 months. The medical records of participants were thoroughly reviewed for information on demographics, ocular history, medical history, number of topical antiglaucoma medications used within the last 6 months, and any other ophthalmic medications used by the participants. An Ocular Surface Disease Index (OSDI) questionnaire was administered to each participant, after which Schirmer test and tear break-up time (TBUT) were performed on each participant in a controlled environment.

RESULTS

A total of 100 individuals participated in the study. The mean±SD age of participants was 60.44±14.05 years. The majority (60.0%) of the participants were females and 55.0% of participants used 2 or more topical antiglaucoma medication. Of the participants, 81.0% reported subjective dry eye symptoms. Schirmer test and TBUT showed that 55.0% and 87.0% of the participants had decreased tear production and abnormal tear quality, respectively. Multiple logistic regression showed a significant association between age and abnormal OSDI (P=0.037), Schirmer test (P=0.003), and TBUT (P=0.042); the number of topical glaucoma medications and OSDI (P=0.016) and Schirmer test (P=0.009). The prevalence of DED was 23.0%. Increasing age was associated with an ∼7 times higher odds of having DED (P=0.0019), using >2 glaucoma medications with ∼4.5 times higher odds of having DED (P=0.001), 5 or more years of glaucoma medication use with ∼4 times higher odds of DED (P=0.009), and both benzalkonium chloride and sodium chlorite as preservative was associated with ∼3.5 times higher odds of DED (P=0.047).

CONCLUSION

DED is prevalent among glaucoma patients in Ghana and is associated with age, duration of glaucoma medication, type of preservatives, and number of topical glaucoma medications.

Quality of Life in Primary Open-Angle Glaucoma and Cataract: An Analysis of VFQ-25 and OSDI From the iStent inject® Pivotal Trial

OBJECTIVE

To assess quality of life (QOL) as measured by patient-reported outcomes (PRO) within the iStent inject® pivotal trial.

DESIGN

Randomized controlled trial analysis of secondary outcomes.

METHODS

The Vision Function Questionnaire (VFQ-25) and Ocular Surface Disease Index (OSDI) questionnaire were administered at baseline and at months 1, 6, 12, and 24. PRO responders were defined as patients reaching improvement based on minimally important differences.

RESULTS

A total of 505 patients were randomized (386 iStent inject® [Glaukos], 119 surgery alone). The iStent inject® group exhibited a greater percentage of PRO responders across all follow-up visits over 24 months, averaging 58.0% vs 45.8%; P < .05 for VFQ-25 composite scores and 56.7% vs 48.9%; P < .05 for OSDI composite scores. Odds of being a responder in the iStent inject® group was 60% (P < .05) higher for the VFQ-25 and 32% (P > .05) higher for the ODSI. Driving (49.0% vs 28.8%; P < .05), ocular pain (59.3% vs 47.2%; P < .05), and general vision (71.8% vs 60.0%; P < .05) were the VFQ-25 subscales responsible for differences between treatment groups. At month 24, 76.5% of VFQ-25 responders and 62.5% of nonresponders were medication free regardless of treatment group (P < .05).

CONCLUSIONS

Exploratory analysis suggests that by reducing medication dependence, implantation with the micro-scale iStent inject® device with cataract surgery may improve QOL vs cataract surgery alone over 24 months, with improvements influenced by ocular symptoms and vision-related activities.

Funktionelle Sehschärfe beim Trockenen Auge

Das Trockene Auge führt häufig zu Sehstörungen trotz guter Sehleistung in der Standardvisusprüfung. Die Beschwerden treten meist beim Lesen, Arbeiten am Computer und/oder beim Autofahren auf. Grund ist die schlechte optische Qualität der Augenoberfläche beim Trockenen Auge mit Zunahme von topometrischer Irregularität und Asymmetrie, Anstieg des irregulären Astigmatismus, Zunahme der kornealen und okulären Aberrationen höherer Ordnung, Abnahme der Kontrastsensitivität und Zunahme der Lichtstreuung. Die funktionelle Sehschärfe repräsentiert die Visusfunktion im Zeitverlauf und reflektiert die Visusleistung eines Individuums bei täglichen Aktivitäten. Sie ist beim Trockenen Auge signifikant reduziert im Vergleich zu Normalprobanden. Eine Vielzahl von Testmethoden zur Evaluierung der funktionellen Sehschärfe wurde beschrieben. Kein Verfahren hat sich bisher in der täglichen Praxis durchgesetzt.

Assessment of patient burden from dry eye disease using a combination of five visual analogue scales and a radar graph: a pilot study of the PENTASCORE

BACKGROUND/AIMS

Dry eye disease (DED) questionnaires would ideally be easy and fast to answer and explore the main aspects of disease burden and satisfaction (efficacy and tolerability) with treatment. This pilot study evaluates the Pentascore questionnaire for routinely assessing DED.

METHODS

The Pentascore combines five visual analogue scales (VAS) to assess the intensity and frequency of ocular pain/discomfort, the impact of DED on daily activities and visual tasks and the efficacy and tolerability of ongoing DED treatment(s). This retrospective study compared Pentascore to the Ocular Surface Disease Index (OSDI) questionnaire, fluorescein tear break-up-time, corneal staining and Schirmer I test.

RESULTS

For 161 DED patients, the algebraic mean (±SE) for the Pentascore was 52.6±1.8, the mean standardised area of the radar graph was 32.1±1.7 (out of 100) and the mean score for the OSDI was 52.6±1.8. Both questionnaires were highly statistically correlated (R=0.74 for both algebraic score and radar area, p<0.001), and each of five Pentascore VAS was significantly correlated with the OSDI (p<0.05). Corneal staining score (CSS) was correlated with two Pentascore VAS (impact of DED on daily activities and visual tasks), and there was a trend towards a correlation between CSS and the area of the radar graph (p=0.09).

CONCLUSIONS

This pilot study indicates that the Pentascore can rapidly and effectively assess the burden of DED and satisfaction with treatments. Compared with the algebraic mean, the estimation of the area of the radar graph likely improves the sensitivity for detecting differences/changes in symptoms and treatment follow-up.

Dry eye disease symptoms and quality of life in perimenopausal and postmenopausal women

OBJECTIVE

This study aimed to evaluate dry eye disease (DED) symptoms and quality of life (QoL) in a group of perimenopausal and postmenopausal women, based on the Ocular Surface Disease Index (OSDI) questionnaire.

METHODS

An observational study was performed in a group of 1947 perimenopausal and postmenopausal women, aged between 45 and 79 years. The personal data collected were age, menopause status, age at menopause, and OSDI score.

RESULTS

The mean age of the group was 54.18 ± 6.84 years, with a mean age at menopause of 49.45 ± 4.02 years. The average OSDI score was 29.20 ± 19.4. The overall prevalence of DED symptoms was 79%, increasing significantly in postmenopausal women, 76.4% vs. 80.5% (p = 0.029). In our group, 37.7% had severe DED symptoms. Ocular symptoms, vision-related functions, and environmental trigger scores were higher in postmenopausal women, leading to a lower QoL. The severity of OSDI score increases with age (β coefficient: 0.15 [95% confidence interval: 0.02; -0.28]), while the severity of OSDI score decreases with a later onset age of menopause (β coefficient: -0.27 [95% confidence interval: -0.55; -0.01]).

CONCLUSIONS

DED symptoms are highly prevalent in perimenopausal and postmenopausal women. Postmenopausal women had a higher prevalence of symptoms and higher OSDI scores than perimenopausal women. The severity of DED symptoms and vision-related functions leads to poorer QoL.

Study of tear film optics and its impact on quality of vision

Purpose:

To evaluate the relation of the tear film on the quality of vision comparing parameters in normal patients to those having dry eye disease.

Methods:

50 normal and 50 eyes with dry eye disease (DED) were included in the study. Patients were screened for dry eye with Schirmer's test, tear break up time, ocular surface staining, and assessment of meibomian gland disease. Their quality of vision was assessed using the Optical quality analysis system (OQAS). The results of dry eye evaluation were correlated with the parameters on the OQAS especially the mean objective scatter index (OSI).

Results:

Patients with dry eye and unstable tear film were found to have a significantly worse quality of vision and optical scatter (P < 0.05). They were also noted to have fluctuation of vision between blinks.

Conclusion:

Tear film optics can have an important bearing on the quality of vision and quality of life. A detailed assessment preoperatively will help improve surgical outcomes and patient satisfaction.

Novel Approaches for Imaging-Based Diagnosis of Ocular Surface Disease

Imaging has become indispensable in the diagnosis and management of diseases in the posterior part of the eye. In recent years, imaging techniques for the anterior segment are also gaining importance and are nowadays routinely used in clinical practice. Ocular surface disease is often synonymous with dry eye disease, but also refers to other conditions of the ocular surface, such as Meibomian gland dysfunction or keratitis and conjunctivitis with different underlying causes, i.e., allergies or infections. Therefore, correct differential diagnosis and treatment of ocular surface diseases is crucial, for which imaging can be a helpful tool. A variety of imaging techniques have been introduced to study the ocular surface, such as anterior segment optical coherence tomography, in vivo confocal microscopy, or non-contact meibography. The present review provides an overview on how these techniques can be used in the diagnosis and management of ocular surface disease and compares them to clinical standard methods such as slit lamp examination or staining of the cornea or conjunctiva. Although being more cost-intensive in the short term, in the long term, the use of ocular imaging can lead to more individualized diagnoses and treatment decisions, which in turn are beneficial for affected patients as well as for the healthcare system. In addition, imaging is more objective and provides good documentation, leading to an improvement in patient follow-up and education.

Acupuncture for the treatment of dry eye: Protocol for systematic review and meta-analysis

BACKGROUND

As a common ophthalmic disease, dry eye (DE) may bring several adverse effects on the quality of life for patients. In recent years, Acupuncture (AC) is becoming increasingly popular for treating DE. Thus, we conceived this systematic review aims to evaluate the effectiveness and safety of AC for DE objectively.

METHODS

The search results are restricted to randomized controlled trials and human studies. We will establish the inclusion criteria through discussion and design a detailed literature search strategy for each database. Articles are searched from 4 English databases (the Cochrane Library, PubMed, Web of Science, and EMBASE) and 4 Chinese databases (Wangfang, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Chinese scientific and technical journals database). The relevant studies published from the date of database inception until January 2020 will be collected. We will also search (International Clinical Trials Registry Platform), PROSPERO, and potential gray literature. Two reviewers independently perform literature screening, information extraction, and assessment of study quality. The outcome measures include primary outcome measures (Schirmer I test and break-up time), secondary outcome measures (Ocular Surface Disease Index, corneal fluorescein staining, and tear osmolarity), and safety outcome measures. Assessment of bias risk and data processing are performed using RevMan 5.3 software ( the Nordic Cochrane Centre, Copenhagen, Denmark).

RESULTS

We will evaluate the curative effect of AC for DE comprehensively based on multiple outcome measures.

CONCLUSION

This systematic review will provide evidence for the effectiveness and safety of AC in the treatment of DE.

PROSPERO NUMBER

CRD42019144790.

Assessment of tear film optical quality in a young short tear break-up time dry eye: Case-control study

BACKGROUND

The aim of the study was to evaluate the dynamic changes of tear film optical quality in a short tear break-up time (TBUT) dry eye by using a double-pass system.

METHODS

Thirty-five short TBUT dry eye participants and 43 control subjects without dry eye were included in this study. One eye for each subject was analyzed. The Objective Scatter Index (OSI), modulation transfer function (MTF), and strehl ratio (SR) were recorded within a 20-second period with the participants asked to blink freely, and 10 successive seconds of nonblinking immediately after a blink was recorded to analyze the tear film OSI. The mean tear film OSI in 10 successive seconds, ΔOSI, and ΔOSI/time were evaluated. The correlation between tear film OSI and MTF, and the correlation between tear film OSI and MIT were also analysed.

RESULTS

Short TBUT dry eye participants showed significant deterioration of MTF and SR compared to control subjects. The mean tear film OSI in 10 successive seconds was significantly higher in dry eye participants than in control subjects. The mean OSI of the tear film (0-5 seconds) and the mean OSI of the tear film (6-10 seconds) were significantly higher in dry eye participants than in control participants. Moreover, the ΔOSI was significantly higher in dry eye participants than in control participants. The tear film OSI was significantly correlated with the MTF and the SR.

CONCLUSIONS

The tear film OSI of short TBUT dry eye participants is significantly increased in the early stage. Tear film instability in short TBUT dry eye participants has a significant effect on optical quality.

Comparison of Visual, Refractive and Ocular Surface Outcomes Between Small Incision Lenticule Extraction and Laser-Assisted In Situ Keratomileusis for Myopia and Myopic Astigmatism

Laser-assisted in situ keratomileusis (LASIK) is the most commonly performed laser refractive surgical technique worldwide for the treatment of myopia and myopic astigmatism. In recent years, small incision lenticule extraction (SMILE) has emerged as a promising alternative to LASIK, requiring only a single femtosecond laser to create an intrastromal lenticule, which is then removed via a small incision. The technique obviates the need for a corneal flap. A number of published studies have compared the two techniques in terms of visual, refractive and ocular surface outcomes. This review compares the clinical outcomes between LASIK and SMILE in treating myopia and myopic astigmatism based on studies published in the last 5 years. Twenty-two studies were included, all of which were observational in nature. Results suggest that the two techniques have comparable visual outcomes in terms of safety, efficacy and predictability, although recovery in visual acuity may be slower in SMILE-treated than LASIK-treated eyes. SMILE is found to result in less severe postoperative dry eye symptoms and faster recovery of corneal sensitivity than LASIK. It is important to note, however, that the SMILE technique is limited by the lack of a cyclotorsion-compensation system and option for customized treatment profile. The heterogeneity of results in this review may be attributable to the use of different LASIK platforms in different studies. Few studies compared the outcomes regarding severity of myopia. Future prospective randomized controlled trials with a larger sample size and longer follow-up period will be highly beneficial for progress in this field.

Irregular Astigmatism and Higher-Order Aberrations in Eyes With Dry Eye Disease

Visual disturbances were included in the definition of dry eye disease in the 2007 Dry Eye Workshop report. As a result, quality of vision (QoV) in dry eye patients has received increased attention. Corneal topography and wavefront sensors have been used to objectively and quantitatively evaluate optical quality, with data showing increases in irregular astigmatism and higher-order aberrations (HOAs) in dry eye patients. Furthermore, ocular optical characteristics are influenced by the tear film, which constantly fluctuates over time. Therefore, dynamic quantitative assessments of optical quality with continuous measurements are essential to understanding QoV in dry eye patients. This review summarizes what is known and what advances have been made in evaluating and understanding QoV in dry eye patients. In particular, corneal topographic and wavefront analyses, conducted both overseas and in Japan, are described.

[Tear film analysis and evaluation of optical quality: A review of the literature (French translation of the article)]

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

Tear film analysis and evaluation of optical quality: A review of the literature

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

The impact of dry eye disease treatment on patient satisfaction and quality of life: A review

Several aspects of the quality of life (QoL) and treatment satisfaction of patients with dry eye disease (DED) may be underestimated. Ocular symptoms, which are assessed by validated patient-reported questionnaires and may include stinging, burning, itchiness, grittiness, dryness and discomfort, reduce QoL by affecting daily activities and work productivity. Self-reported symptoms do not always correlate with post-treatment improvements in clinical measures such as tear film break-up time, inflammation and osmolarity. Thus, treatments may improve clinical ocular features without improving symptoms that affect daily life. This review explores 1500 abstracts from congress presentations and peer-reviewed journals for QoL and treatment satisfaction data on the use of active lubricants, osmoprotectants, secretagogues, and immunomodulators present in topical formulations for DED treatment, and validated symptom questionnaires. Patient-reported symptoms of DED are generally improved after treatment with topical formulations for tear replacement, tear stimulation or anti-inflammatory therapy compared with baseline or a control treatment. However, more data are required to compare the performance of active ingredients. It is fundamental to diagnose patients with DED accurately, recognising the major cause behind their dry eyes. Studies are also necessary to identify how patient satisfaction and QoL may be improved through long-term use of topical preparations. We conclude that careful and thorough consideration of patient-reported symptoms should be integrated into DED management to help tailor treatment to patient needs.

Effect of 5-Oxo-2-Pyrrolidinecarboxylic Acid (PCA) as a New Topically Applied Agent for Dry Eye Syndrome Treatment

The aim of the study was the evaluation of the suitability of 5-oxo-2-pyrrolidinecarboxylic acid (PCA), also in combination with hyaluronic acid (HA), as artificial tears for treatment of dry eye syndrome (DES). Different aqueous formulations containing 0.10% w/w of PCA were used to determine: (i) ex vivo permeation profile of PCA in isolated rabbit corneas; (ii) in vivo residence time of PCA in the precorneal area of rabbits; and (iii) in vivo ability of PCA to counteract the reduction of tear production in an experimental model of DES induced in rabbits. The pharmacokinetic profile of PCA in tear fluid was characterized by high concentrations immediately after application, followed by a rapid decrease, with half-life values of 17.16 and 22.27 min for solutions containing PCA alone and in combination with HA, respectively, when 100 µL of solutions were instilled. The addition of HA almost doubled the PCA bioavailability minimizing the ex vivo apparent corneal permeability of PCA. A positive Shirmer Test Score (STS) was observed for PCA compared to contralateral eyes at all days of treatment for PCA/HA formulation. PCA provides protection from desiccation probably for its osmoprotective activity and high water⁻binding capability, and this behaviour was enhanced by HA.

Impact of Dry Eye Disease on Vision Quality: An Optical Quality Analysis System Study

Purpose

We evaluated the relationship between ocular surface clinical tests and quality of vision in patients with dry eye disease (DED).

Methods

In this study, 136 eyes of 72 dry eye patients were evaluated retrospectively using the ocular surface disease index (OSDI), measurement of tear film break-up time (TBUT), the Oxford score, Van Bijsterveld score, and Schirmer I test. Quality of vision was assessed with the optical quality analysis system (OQAS) using the objective scatter index (OSI) recorded over 20 seconds without blinking. Correlations between dry eye symptoms and signs, and OSI measurements were evaluated.

Results

The OSI and OSI standard deviation (OSI SD) were correlated with TBUT (r = -0.21, P = 0.013 and r = -0.18, P = 0.038, respectively), Oxford score (r = 0.31, P = 0.0002 and r = 0.18, P = 0.032, respectively), and the Van Bijsterveld score (r = 0.33, P = 0.0001 and r = 0.25, P = 0.003, respectively). The OSI also was correlated with the Schirmer test (r = -0.19, P = 0.025), OSDI (r = 0.17, P = 0.04), and the ocular symptoms subscale of the OSDI (r = 0.21, P = 0.01). OSI SD was correlated with the environmental triggers subscale of the OSDI (r = 0.21, P = 0.016).

Conclusions

Quality of vision measured with the OQAS was correlated with dry eye symptoms and signs. The OQAS could be a useful tool to better evaluate visual function in patients with DED.

Translational Relevance

The OQAS provides a better understanding of patient complaints about alteration of vision quality. It might be useful to integrate this objective system in severity assessments and follow-up of DED, especially for treatment evaluations.

Effects of tear film dynamics on quality of vision

The precorneal tear film is maintained by blinking and exhibits different phases in the tear cycle. The tear film serves as the most anterior surface of the eye and plays an important role as a first refractive component of the eye. Alterations in tear film dynamics may cause both vision-related and ocular surface-related symptoms. Although the optical quality associated with the tear film dynamics previously received little attention, objective measurements of optical quality using wavefront sensors have enabled us to quantify optical aberrations induced by the tear film. This has provided an objective method for assessing reduced optical quality in dry eye; thus, visual disturbances were included in the definition of dry eye disease in the 2007 Dry Eye Workshop report. In addition, sequential measurements of wavefront aberrations have provided us with valuable insights into the dynamic optical changes associated with tear film dynamics. This review will focus on the current knowledge of the mechanisms of wavefront variations that are caused by different aspects of tear film dynamics: specifically, quality, quantity and properties of the tear film, demonstrating the respective effects of dry eye, epiphora and instillation of eye drops on the quality of vision.

Proinflammatory Markers, Chemokines, and Enkephalin in Patients Suffering from Dry Eye Disease

Dry eye symptoms are among the leading complaints in ophthalmology. Dry eye disease (DED) is associated with significant pain affecting quality of life. Cellular and molecular mechanisms underlying ocular pain associated with DED are not fully understood. In this study, we investigated the ocular surface of patients with DED using in vivo confocal microscopy (IVCM) to quantify corneal nerve density and its relation with corneal inflammation. Gene expression of the proinflammatory markers HLA-DR, IL-6, CXCL12, and CCL2 and the receptors CXCR4 and CCR2, as well as PENK (enkephalin precursor), was therefore quantified in conjunctival impression cytology specimens. Thirty-two patients with DED and 15 age-matched controls were included. Subbasal nerve density was significantly lower in DED patients compared to controls. IVCM analysis revealed that DED patients had a significantly higher corneal dendritic cell density compared to controls. Conjunctival impression cytology analysis revealed that HLA-DR, IL-6, CXCR4, and CCL2/CCR2 mRNA levels were significantly increased in DED patients compared to controls, whereas PENK mRNA levels were significantly decreased. Similar results were obtained in vitro on immortalized human conjunctiva-derived epithelial cells challenged with osmotic stress that mimics the DED condition. These results demonstrate that proinflammatory molecules and endogenous enkephalin have opposite gene regulation during DED.

A new dry eye mouse model produced by exorbital and intraorbital lacrimal gland excision

Chronic dry eye is an increasingly prevalent condition worldwide, with resulting loss of visual function and quality of life. Relevant, repeatable, and stable animal models of dry eye are still needed. We have developed an improved surgical mouse model for dry eye based on severe aqueous fluid deficiency, by excising both the exorbital and intraorbital lacrimal glands (ELG and ILG, respectively) of mice. After ELG plus ILG excision, dry eye symptoms were evaluated using fluorescein infiltration observation, tear production measurement, and histological evaluation of ocular surface. Tear production in the model mice was significantly decreased compared with the controls. The corneal fluorescein infiltration score of the model mice was also significantly increased compared with the controls. Histological examination revealed significant severe inflammatory changes in the cornea, conjunctiva or meibomian glands of the model mice after surgery. In the observation of LysM-eGFP^(+/−) mice tissues, postsurgical infiltration of green fluorescent neutrophils was observed in the ocular surface tissues. We theorize that the inflammatory changes on the ocular surface of this model were induced secondarily by persistent severe tear reduction. The mouse model will be useful for investigations of both pathophysiology as well as new therapies for tear-volume-reduction type dry eye.

Dry eye syndrome: developments and lifitegrast in perspective

Dry eye (DE) is a chronic ocular condition with high prevalence and morbidity. It has a complex pathophysiology and is multifactorial in nature. Chronic ocular surface inflammation has emerged as a key component of DE that is capable of perpetuating ocular surface damage and leading to symptoms of ocular pain, discomfort, and visual phenomena. It begins with stress to the ocular surface leading to the production of proinflammatory mediators that induce maturation of resident antigen-presenting cells which then migrate to the lymph nodes to activate CD4 T cells. The specific antigen(s) targeted by these pathogenic CD4⁺ T cells remains unknown. Two emerging theories include self-antigens by autoreactive CD4 T cells or harmless exogenous antigens in the setting of mucosal immunotolerance loss. These CD4 T cells migrate to the ocular surface causing additional inflammation and damage. Lifitegrast is the second topical anti-inflammatory agent to be approved by the US Food and Drug Administration for the treatment of DE and the first to show improvement in DE symptoms. Lifitegrast works by blocking the interaction between intercellular adhesion molecule-1 and lymphocyte functional associated antigen-1, which has been shown to be critical for the migration of antigen-presenting cells to the lymph nodes as well as CD4⁺ T cell activation and migration to the ocular surface. In four large multicenter, randomized controlled trials, lifitegrast has proven to be effective in controlling both the signs and symptoms of DE with minimal side effects. Further research should include comparative and combination studies with other anti-inflammatory therapies used for DE.

Therapeutic inhibitors for the treatment of dry eye syndrome

INTRODUCTION

Dry eye disease (DED), defined as a multifactorial disease of tears and ocular surface, results in symptoms of discomfort, ocular irritation, visual disturbance and tear film instability. This syndrome is accompanied of ocular surface inflammation and it is produced by a deficient activity of the lacrimal functional unit. In addition, it is associated with systemic autoimmune diseases such as Sjögren´s Syndrome, rheumatoid arthritis, systemic lupus erythematosus and some drug administration. The treatment of dry eye disease is based on the typical signs and symptoms of dry eye, which are associated with hyperosmolarity, ocular surface inflammation, discomfort, visual disturbance, and tear film instability. Areas covered: This review is focused on synthetic drugs currently used in clinical practice, from phase III development onwards to treat the ocular surface signs and symptoms of dry eye disease. Expert opinion: The multifactorial disease and the lack of correlation between signs and symptoms imply that not all the pharmacological approaches will be successful for dry eye. The correct design of the clinical trials, with appropriate endpoints, and the type of dry eye under study are complicated but mandatory. The anti-inflammatory and secretagogues drugs are both the main compounds to currently treat the dry eye disease.

Blink: Characteristics, Controls, and Relation to Dry Eyes

Blink is a complex phenomenon that is profoundly affected by diverse endogenous and exogenous stimuli. It has been studied in the context of cognition, emotional, and psychological states, as an indicator of fatigue and sleepiness, particularly in the automobile and transportation industry, in visual tasking, and finally, as it relates to tear film stability and ocular surface health. The fact that it is highly variable and has input from so many sources makes it very difficult to study. In the present review, the behavior of blink in many of these systems is discussed, ultimately returning in each instance to a discussion of how these factors affect blink in the context of dry eyes. Blink is important to ocular surface health and to an individual's optimal functioning and quality of life. Disturbances in blink, as cause or effect, result in a breakdown of tear film stability, optical clarity, and visual function.

Advances in dry eye imaging: the present and beyond

New advances in imaging allow objective measurements for dry eye as well as define new parameters that cannot be measured by clinical assessment alone. A combination of these modalities provides unprecedented information on the static and dynamic properties of the structural and functional parameters in this multifactorial disease. A literature search was conducted to include studies investigating the use of imaging techniques in dry eye disease. This review describes the application of non-invasive tear breakup time, optical coherence tomography, meibomian gland imaging, interferometry, in vivo confocal microscopy, thermography and optical quality assessment for this condition.

TFOS DEWS II Epidemiology Report

The subcommittee reviewed the prevalence, incidence, risk factors, natural history, morbidity and questionnaires reported in epidemiological studies of dry eye disease (DED). A meta-analysis of published prevalence data estimated the impact of age and sex. Global mapping of prevalence was undertaken. The prevalence of DED ranged from 5 to 50%. The prevalence of signs was higher and more variable than symptoms. There were limited prevalence studies in youth and in populations south of the equator. The meta-analysis confirmed that prevalence increases with age, however signs showed a greater increase per decade than symptoms. Women have a higher prevalence of DED than men, although differences become significant only with age. Risk factors were categorized as modifiable/non-modifiable, and as consistent, probable or inconclusive. Asian ethnicity was a mostly consistent risk factor. The economic burden and impact of DED on vision, quality of life, work productivity, psychological and physical impact of pain, are considerable, particularly costs due to reduced work productivity. Questionnaires used to evaluate DED vary in their utility. Future research should establish the prevalence of disease of varying severity, the incidence in different populations and potential risk factors such as youth and digital device usage. Geospatial mapping might elucidate the impact of climate, environment and socioeconomic factors. Given the limited study of the natural history of treated and untreated DED, this remains an important area for future research.

Characteristics of symptoms experienced by persons with dry eye disease while driving in China

PurposeTo assess the vision-related quality of life and self-reported driving performance of patients with dry eye disease (DED).Patients and methodsThe study was performed in the eye centre of Peking University Third Hospital, China. In total, 87 dry eye patients and 42 controls were enroled, including 49 patients without any treatment (group A), 38 patients treated with artificial tears (group B) and 42 controls without DED (group C). The participants had no eye disease other than DED. Scores of a vision-related quality-of-life questionnaire (Ocular Surface Disease Index (OSDI)), a daily life-related visual function questionnaire and a questionnaire about performance during driving were collected. Data were compared among the groups and analysed.ResultsSignificant differences in all clinical characteristics and OSDI scores were found between DED patients and normal controls (P<0.05). While subjects in group A felt more uncomfortable than those in group B, the functional limitations related to dry eye were significant in all DED patients, especially for daily work and using a computer. DED was correlated with unsafe driving habits and performance, which may increase the risk of dangerous driving (P<0.01). For patients with DED, the rate of accidents and near-accidents was 10.33%, and the rate of missed targets totalled 32.17%.ConclusionsDED can lead to many inconveniences in daily life, including driving. The frequencies of unsafe driving habits and performance were increased in patients with DED.

Corneal Higher-Order Aberrations of the Anterior Surface, Posterior Surface, and Total Cornea After SMILE, FS-LASIK, and FLEx Surgeries

OBJECTIVES

To investigate the corneal higher-order aberrations (HOAs) of the anterior surface, posterior surface, and total cornea after small incision lenticule extraction (SMILE) and compare the results using femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and femtosecond laser lenticule extraction (FLEx).

METHODS

This study included 160 eyes in total; 73 eyes underwent SMILE, 52 eyes underwent FS-LASIK, and 35 eyes underwent FLEx surgery. Corneal HOAs of the anterior surface, posterior surface, and total cornea were evaluated using a Scheimpflug camera over 6-mm diameter preoperatively and 3 months postoperatively.

RESULTS

The anterior and total corneal HOAs significantly increased after SMILE, FS-LASIK, and FLEx surgeries, especially the spherical aberration and coma, whereas most posterior corneal HOAs remained unchanged. The SMILE procedure induced significantly lower anterior corneal and total corneal spherical aberration and third to eighth HOAs compared with FLEx surgery (P<0.01). FLEx surgery induced higher posterior corneal coma than SMILE (P=0.013) and FS-LASIK (P<0.001) surgeries.

CONCLUSIONS

SMILE, FS-LASIK, and FLEx surgeries mainly induced coma and spherical aberrations in the anterior surface and total cornea. The SMILE procedure induced less spherical aberration of the anterior cornea and total cornea than FLEx surgery. The posterior corneal spherical aberration significantly increased after FS-LASIK surgery. The SMILE procedure seems to have fewer effects on posterior corneal coma compared with the FLEx procedure.

New Perspectives on Dry Eye Definition and Diagnosis: A Consensus Report by the Asia Dry Eye Society

For the last 20 years, a great amount of evidence has accumulated through epidemiological studies that most of the dry eye disease encountered in daily life, especially in video display terminal (VDT) workers, involves short tear film breakup time (TFBUT) type dry eye, a category characterized by severe symptoms but minimal clinical signs other than short TFBUT. An unstable tear film also affects the visual function, possibly due to the increase of higher order aberrations. Based on the change in the understanding of the types, symptoms, and signs of dry eye disease, the Asia Dry Eye Society agreed to the following definition of dry eye: "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 definition stresses instability of the tear film as well as the importance of visual impairment, highlighting an essential role for TFBUT assessment. This paper discusses the concept of Tear Film Oriented Therapy (TFOT), which evolved from the definition of dry eye, emphasizing the importance of a stable tear film.

Functional impairment of reading in patients with dry eye

BACKGROUND/AIMS

To evaluate the impact of dry eye on reading performance.

METHODS

Out-loud and silent reading in patients with clinically significant dry eye (n=41) and controls (n=50) was evaluated using standardised texts. Dry eye measures included tear film break-up time, Schirmer's test and corneal epithelial staining. Symptoms were assessed by the Ocular Surface Disease Index (OSDI).

RESULTS

The dry eye group had a greater proportion of women as compared with the control group but did not differ in age, race, education level or visual acuity (p≥0.05 for all). Out-loud reading speed averaged 148 words per minute (wpm) in dry eye subjects and 163 wpm in controls (p=0.006). Prolonged silent reading speed averaged 199 wpm in dry eye subjects versus 226 wpm in controls (p=0.03). In multivariable regression models, out-loud and sustained silent reading speeds were 10 wpm (95% CI -20 to -1 wpm, p=0.039) and 14% (95% CI -25% to -2%, p=0.032) slower, respectively, in dry eye subjects as compared with controls. Greater corneal staining was associated with slower out-loud (-2 wpm/1 unit increase in staining score, 95% CI =-3 to -0.3 wpm) and silent (-2%, 95% CI -4 to -0.6 wpm) reading speeds (p<0.02 for both). Significant interactions were found between OSDI score and word-specific features (longer and less commonly used words) on out-loud reading speed (p<0.05 for both).

CONCLUSIONS

Dry eye is associated with slower out-loud and silent reading speeds, providing direct evidence regarding the functional impact of dry eye. Reading speed represents a measurable clinical finding that correlates directly with dry eye severity.

A Randomized, Controlled Study of the Efficacy and Safety of a New Eyedrop Formulation for Moderate to Severe Dry Eye Syndrome

Purpose

This study compared the efficacy and safety of hyaluronic acid (HA)-trehalose, a new eyedrop containing trehalose (a natural bioprotectant) and HA, to an established formulation containing only HA.

Methods

This was a phase III, randomized, active-controlled, investigator-masked, multicenter study in France and Tunisia. In all, 105 adult patients (≥18 years) with moderate to severe dry eye disease (DED) received either HA-trehalose (n = 52) or HA (n = 53) 3-6 times per day for 84 days. The primary efficacy variable was the Oxford grading score at day 35. A questionnaire on dry eye and symptoms, Schirmer test, tear break-up time, conjunctival hyperemia, and global performance were assessed as secondary efficacy criteria at baseline, day 35, and day 84. Safety assessments were standard.

Results

Noninferiority of HA-trehalose to HA for keratoconjunctivitis sicca assessed by Oxford grading score was demonstrated at day 35. For the secondary efficacy parameters, reductions in dry eye questionnaire classes of none or mild at day 84, dry eye symptoms of stinging, itching, and blurred vision at day 35, and investigator (days 35 and 84) and patient assessments (day 35) of global performance were significantly better for HA-trehalose. There were no clinically meaningful differences between groups for the other secondary criteria. Both treatments were well-tolerated, and there were fewer ocular symptoms upon instillation and fewer adverse events for HA-trehalose than for HA.

Conclusions

Hyaluronic acid-trehalose is effective and safe, with better patient satisfaction, than existing HA-only eyedrops particularly from the first month of treatment, and offers a therapeutic advancement in the treatment of moderate to severe DED.

The IMPACT study: a prospective evaluation of the effects of cyclosporine ophthalmic emulsion 0.05% on ocular surface staining and visual performance in patients with dry eye

Objective

The aim of this study was to evaluate the effects of cyclosporine ophthalmic emulsion 0.05% on ocular surface staining and visual performance in patients with dry eye.

Methods

This was a single-center, 6-month, open-label, Phase IV study. Patients with bilateral dry eye disease and a symptom score of ≥2 on the Ocular Discomfort and 4-Symptom Questionnaire, an Ocular Surface Disease Index score of >12, at least one eye with Schirmer’s score <10 mm/5 minutes, and central corneal staining graded as ≥2 on the Ora Calibra™ Corneal and Conjunctival Staining Scale were enrolled. Cyclosporine ophthalmic emulsion 0.05% (Restasis^®) was instilled twice daily in each eye. The primary efficacy endpoints were ocular surface staining and visual function at 6 months. Secondary outcome measures included Schirmer’s test, tear film breakup time, symptoms, and adverse events.

Results

A total of 40 patients with the mean age of 59.4 years (range, 40–78 years) were enrolled; 35 (87.5%) were female and 37 (92.5%) completed the study. At 6 months, inferior corneal, central corneal, total corneal, and total ocular surface fluorescein staining were significantly improved from baseline in both eyes (P<0.001). Patient responses on the Ocular Surface Disease Index showed significant improvement in blurred vision and visual function related to reading, driving at night, working with a computer or bank machine, and watching television (P≤0.041). At 6 months, 35.1% of patients achieved ≥5 mm improvement and 18.9% achieved ≥10 mm improvement in the average eye Schirmer score. Mean tear film breakup time improved by >50% in both eyes (P>0.001). Patients reported significant improvement in ocular discomfort and dry eye symptoms (P<0.001). No patients discontinued treatment because of stinging or any other ocular adverse event.

Conclusion

Dry eye patients with difficulties with day-to-day visual function demonstrated improvement in both signs and symptoms of dry eye and reported improved visual function after 6 months of treatment with cyclosporine ophthalmic emulsion 0.05%.