TFOS lifestyle: Impact of societal challenges on the ocular surface

Long term stability of preservative-free and lyophilized PRGF eye drops stored at different temperature conditions: in vitro comparative study

Long-term stability of blood-derived eye drops is required to adapt the use of this treatment to prolonged clinical treatments and more green pharmacy. This study has been designed to assess the long-term storage life of freeze-dried plasma rich in growth factors (PRGF) eye drops, maintaining their biological content and activity. Thus, blood from five healthy donors was extracted and centrifuged for obtaining PRGF. The obtained PRGF eye-drops after platelet activation were freeze-stored or were lyophilized and then stored for 18 and 24 months at room temperature (RT) or at + 5 °C. Growth factor content and proliferative potential of PRGF eye drops on primary human keratocytes (HK) was evaluated at each storage time and condition. All growth factors maintained their levels at each time and storage condition. No differences were observed on the proliferative activity of keratocytes after treatment with freeze-dried PRGF eye-drops stored at RT or +5 °C for 18 or 24 months in comparison with fresh samples. No microbial contamination was observed in any of the PRGF eye-drops. Accepting the limitations of this study, it is observed that freeze-dried PRGF eye drops retain both key growth factors and biological activity when stored at room temperature or +5 °C for up to 18-24 months.

Artificial intelligence models utilize lifestyle factors to predict dry eye related outcomes

The purpose of this study is to examine and interpret machine learning models that predict dry eye (DE)-related clinical signs, subjective symptoms, and clinician diagnoses by heavily weighting lifestyle factors in the predictions. Machine learning models were trained to take clinical assessments of the ocular surface, eyelids, and tear film, combined with symptom scores from validated questionnaire instruments for DE and clinician diagnoses of ocular surface diseases, and perform a classification into DE-related outcome categories. Outcomes are presented for which the data-driven algorithm identified subject characteristics, lifestyle, behaviors, or environmental exposures as heavily weighted predictors. Models were assessed by 5-fold cross-validation accuracy and class-wise statistics of the predictors. Age was a heavily weighted factor in predictions of eyelid notching, Line of Marx anterior displacement, and fluorescein tear breakup time (FTBUT), as well as visual analog scale symptom ratings and a clinician diagnosis of blepharitis. Comfortable contact lens wearing time was heavily weighted in predictions of DE symptom ratings. Time spent in near work, alcohol consumption, exercise, and time spent outdoors were heavily weighted predictors for several ocular signs and symptoms. Exposure to airplane cabin environments and driving a car were predictors of DE-related symptoms but not clinical signs. Prediction accuracies for DE-related symptoms ranged from 60.7 to 86.5%, for diagnoses from 73.7 to 80.1%, and for clinical signs from 66.9 to 98.7%. The results emphasize the importance of lifestyle, subject, and environmental characteristics in the etiology of ocular surface disease. Lifestyle factors should be taken into account in clinical research and care to a far greater extent than has been the case to date.

Expert consensus on pediatric dry eye: Insights from a European Delphi study

CONTEXT

Dry Eye Disease (DED) is a symptomatic multifactorial condition of the ocular surface, primarily characterized by tear film instability, which can lead to ocular surface damage. While traditionally associated with adults, recent studies have shown a significant prevalence of DED in pediatric populations, exacerbated by modern lifestyle changes such as increased screen time and environmental factors. Pediatric DED (PeDED) often goes underdiagnosed due to a lack of tailored diagnostic tools and the misattribution of symptoms to other conditions.

METHODS

This Delphi study, conducted by a European panel of six ophthalmology experts sought to address expert consensus in pending challenges of PeDED.

RESULTS

Over two rounds of surveys, 34 experts reached consensus on 39 of 46 statements, highlighting the need for age-specific diagnostic criteria and treatment protocols. The study identified environmental and lifestyle factors, such as screen time and ocular allergies, as significant risk factors for PeDED. There was strong consensus on the importance of adapting adult DED definitions and treatment approaches to better suit pediatric patients. The study also emphasized the cautious use of treatments like topical steroids or oral macrolides, especially in younger children.

CONCLUSION

The findings underscore the necessity for standardized clinical practices in diagnosing and managing PeDED, with a focus on improving the quality of life for affected children. Further research is required to validate these findings and develop comprehensive guidelines that cater to the unique needs of the pediatric population.

Profiling eyewash usage and preferences in individuals with hay fever using a digital cross-sectional cohort study with AllerSearch

Eye washing is a common over-the-counter, self-administered method for managing hay fever-related ocular symptoms. However, epidemiological data on eyewash users with hay fever and their characteristics are limited. This study aimed to profile eyewash usage and preferences in individuals with hay fever. This digital, cross-sectional cohort study was conducted between February 2018 and May 2020. Individuals in Japan who downloaded the AllerSearch smartphone application were included. Factors associated with eyewash and non-eyewash users among patients with hay fever were assessed using multivariable logistic regression analyses. Of the 11,284 participants, 9,041 had hay fever. Among them, 40.7% were eyewash users (43.9% used eyewash products as needed during symptom flare-ups, 24.8% used them in the morning, and 19.4% in the evening). Factors associated with eyewash use included younger age, previous psychiatric illness, history of contact lens use, current contact lens use, active smoking, higher yogurt intake, lower nasal symptom score, higher non-nasal symptom score, and dry eye symptoms. Non-use of eyewash was linked to older age, sleep duration < 6 h, lower yogurt intake, and dry eye symptoms. This study elucidated characteristics and factors associated with eyewash use among individuals with hay fever, guiding an individualized approach to treatment and public health initiatives.

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.

A topological-aware automatic grading model corneal epithelial damage evaluation from full Corneal Fluorescence Staining images

Corneal Fluorescence Staining (CFS) imaging is commonly employed for assessing corneal epithelial damage. Automating the grading of CFS images can minimize subjectivity in clinical evaluations and enhance diagnostic efficiency. Existing methods typically depend on the texture and morphological information extracted from whole CFS images, often neglecting the spatial and distribution information between stained regions. This oversight hinders the accurate evaluation of corneal epithelial injury states. This study proposes a three-stage automatic corneal epithelial damage assessment model for full CFS images, optimizing grading by considering topological features among detected stained regions, which are crucial for accurately interpreting the spatial properties of objects within an image. Accurate corneal localization, robust to variations in contrast, is first achieved by integrating CFS images' intensity and phase information, subsequently by a multi-scale morphological top-hat operator concerning their prior shape to detect the stained regions. Finally, a multi-scale graph structure is constructed based on the detected stained areas, and distance-weighted topological features, along with textural and morphological features, are extracted into an automatic grading model based on an ensemble model. Experiments on an in-house dataset of CFS images annotated with six categories of Ocular Surface Staining (OSS) scores reveal that incorporating topological features achieves the highest Accuracy (0.7589), F1 score (0.7449), and AUC (0.9335). Moreover, topological features outperformed other individual features. These findings underscore the effectiveness of our proposed model in CFS grading, indicating its potential for assessing corneal epithelial damage. Additionally, the valuable insights provided by topological features into the spatial distribution patterns of staining suggest promising applications for enhancing disease classification and supporting more informed clinical decision-making in managing dry eye conditions.

[Heavy metals and derangement in carbohydrate metabolism in eye diseases: a systematic review]

PURPOSE

To uncover the negative impacts of heavy metals on carbohydrate metabolism, their mechanisms and contributory factors, as well as their role on the etiopathogenesis, pathophysiology, and progression of eye diseases.

MATERIAL AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), various databases were searched (e.g., Scopus, PubMed, etc.) to collect evidence on the link and role of heavy metals in carbohydrate metabolism and pathogenesis of eye diseases. Included studies were appraised for quality using the Critical Appraisal Skills Programme checklists and extracted data were analyzed using the narrative synthesis method.

RESULTS

Of the 128 papers retrieved, 24 papers met the inclusion criteria. Heavy metals are associated with the onset and progression of diabetes and eye diseases secondary to diabetes (age-related macular degeneration, cataract, and diabetic retinopathy) majorly via toxic interference (induction, inhibition and/or deactivation) of glucose metabolizing enzymes and oxidative stress. The etiology of DR is intricate and includes the simultaneous disruption of several metabolic and signaling mechanisms within the retinal neurovascular unit. The retina is more susceptible to metal-induced toxicities due to the high affinity of heavy metals to melanin content of the retinal epithelium.

CONCLUSION

This study emphasizes the harmful effects of chronic and intermittent exposure to heavy metals, suggesting no safe exposure levels. To prevent eye diseases secondary to heavy metals-induced altered carbohydrate metabolism, metal chelators, low glycemic diets, and lifestyle modifications should be exploited among vulnerable populations.

Ocular Surface Disease and Dry Eye Severity in Glaucoma Patients at Urban Private Eye Care Centres in Malaysia

Background

Ocular surface disease (OSD) severity varies among glaucoma patients and is exacerbated by intraocular pressure (IOP)-lowering medications.

Purpose

To determine OSD prevalence and dry eye severity among glaucoma patients at nine private clinics in Malaysia.

Methods

This multicentre, cross-sectional observational study recruited glaucoma patients undergoing routine eye examinations, with IOP ≤21mmHg receiving anti-glaucoma eye drops. OSD was assessed through National Eye Institute (NEI) scoring, tear film break-up time (TBUT), hyperaemia grading, Schirmer's tests and questionnaires on symptom evaluation, OSD index and quality of life (QoL).

Results

Our cohort (n = 406, mostly male, ethnically Chinese, mean 63.5 ± 11.5 years, mean IOP 15.34 ± 2.95mmHg) frequently used prostaglandin analogues or PGA/beta-blockers and had cornea total NEI scores of 3.64 ± 2.76, mostly with minimal (51.2%) or mild (40.4%) epitheliopathy. Mean TBUT was 6.59 ± 3.08s (25.0%) in patients with severe lipid deficiency dry eye (DE). Bulbar conjunctiva hyperemia (70.4%) and palpebral conjunctiva hyperemia (68.0%) were mild. Schirmer's test showed that most had tear deficiency (70.2%) with severe DE (38.9%). Questionnaires reported ocular symptoms in few patients, but 69.2% had DE symptoms (13.1% moderate/severe). While QoL was good, several patients had QoL and OSD index scores suggesting some adaptation to ocular symptoms and discomfort, with most patients being unconcerned (43-60%) by the occurrence of eye drop side effects (75.4%).

Conclusion

Normal-mild DE or OSD can be asymptomatic, and the symptoms are unlikely to bother most patients. However, as OSD severity varies in patients with glaucoma, it should be evaluated using questionnaires and clinical tests to ensure that subjectively asymptomatic individuals are not missed.

Epidemiology and Risk Factors of Dry Eye Disease: Considerations for Clinical Management

Dry eye disease is a multifactorial condition characterised by tear film instability, hyperosmolarity and ocular surface inflammation. Understanding the epidemiology of dry eye disease and recognising both modifiable and non-modifiable risk factors can assist eye care practitioners in assessing, treating, and managing patients with the condition. This review considers current knowledge surrounding its incidence and prevalence, as well as associated demographic, systemic, ocular, and iatrogenic, and lifestyle-related modifiable risk factors. Population-based prevalence estimates vary according to the diagnostic criteria used to define dry eye disease, as well as severity and demographic characteristics of the population. Considering recent data and variable population demographics, conservative prevalence estimates suggest that 10-20% of the population over 40 years of age report moderate to severe symptoms and/or seek treatment for dry eye disease. Individuals with specific non-modifiable demographic risk factors may be at increased risk of developing dry eye disease. Advanced age, female sex and East Asian ethnicity have been identified as key non-modifiable demographic features predisposing individuals to dry eye disease. Systemic conditions that have been associated with an increased risk of dry eye disease include migraine, Sjögren syndrome, connective tissue disorders, mental health disorders, diabetes mellitus and androgen deficiency. Medications that may contribute to this risk include antidepressants, antihistamines, and hormone replacement therapy. Ocular and iatrogenic risk factors of dry eye disease include blepharitis, Demodex infestation, ocular surgery, blink completeness, contact lens wear, and topical ophthalmic medications. A range of modifiable lifestyle factors that can increase the risk of dry eye disease have also been identified, including low humidity environments, digital screen use, quality of sleep, diet, and eye cosmetic wear. Dry eye is a common disease affecting millions globally. Increasing knowledge regarding its associated risk factors can better prepare the eye care practitioner to successfully manage patients with this ocular surface disease.

Circadian disruption reduces MUC4 expression via the clock molecule BMAL1 during dry eye development

Circadian disruption, as a result of shiftwork, jet lag, and other lifestyle factors, is a common public health problem associated with a wide range of diseases, such as metabolic disorders, neurodegenerative diseases, and cancer. In the present study, we established a chronic jet lag model using a time shift method every 3 days and assessed the effects of circadian disruption on ocular surface homeostasis. Our results indicated that jet lag increased corneal epithelial defects, cell apoptosis, and proinflammatory cytokine expression. However, the volume of tear secretion and the number of conjunctival goblet cells did not significantly change after 30 days of jet lag. Moreover, further analysis of the pathogenic mechanism using RNA sequencing revealed that jet lag caused corneal transmembrane mucin deficiency, specifically MUC4 deficiency. The crucial role of MUC4 in pathogenic progression was demonstrated by the protection of corneal epithelial cells and the inhibition of inflammatory activation following MUC4 replenishment. Unexpectedly, genetic ablation of BMAL1 in mice caused MUC4 deficiency and dry eye disease. The underlying mechanism was revealed in cultured human corneal epithelial cells in vitro, where BMAL1 silencing reduced MUC4 expression, and BMAL1 overexpression increased MUC4 expression. Furthermore, melatonin, a circadian rhythm restorer, had a therapeutic effect on jet lag-induced dry eye by restoring the expression of BMAL1, which upregulated MUC4. Thus, we generated a novel dry eye mouse model induced by circadian disruption, elucidated the underlying mechanism, and identified a potential clinical treatment.

Expression of Hormones' Receptors in Human Corneal Endothelium from Fuchs' Dystrophy: A Possible Gender' Association

Background: Age and sex are the most significant risk of factors for advanced Fuchs dystrophy. Nevertheless, few data are available on the hormone's receptor pattern expressed in adult and advanced fuchs endothelial corneal dystrophy (FECD). We investigated the impact of gender, growth factors and extracellular matrix (ECM) regulatory proteins expressed by the dystrophic endothelia. Methods: Ten dystrophic endothelial tissues and 10 normal endothelial sheets (corneoscleral specimens; Eye Bank) were used for this characterization study. Hormones' receptors (ERα, AR, PR, SHBG), few growth factors (VEGFA, βNGF, TGFβ1), some ECM regulators (MMP1, MMP7) and few inflammatory cytokines (IFNγ, IL10) were analyzed by real-time RT-PCR. Results: ERα transcripts were significantly increased, AR and SHBG transcripts were decreased in Fuchs endothelia from female patients, and no changes were detected for PR transcripts. VEGFA, βNGF and TGFβ1 transcripts were upregulated in Fuchs' endothelia, but not significantly linked to gender. High MMP1 and low MMP7 transcripts' expression were detected in Fuchs' specimens, mainly in males than females. An increased IFNγ (Th1) transcript expression was observed in females than males, and a trend to increase for IL10 (Th2) transcripts was detected in males than females. Conclusions: Our findings clearly indicate that hormone receptors, growth factors and matrix mediators as well as a Th1 pathway are predominant in Fuchs' dystrophy, displaying a pattern of expression specific for the female phenotype. The differential expression of hormones' receptors and the Th1/Th2 ratio might prompt to new theories to be tested in vitro and in vivo models, such as the use of hormonal substitute for counteracting this endothelial cell lost.

Different concentrations of hyaluronic acid eye drops for dry eye syndrome: a systematic review and Meta-analysis

AIM

To compare high or low concentration of hyaluronic acid eye drops (HY) for dry eye syndromes (DES).

METHODS

Randomized controlled trials (RCTs) comparing various concentrations of HY were searched in PubMed, Embase, Web of Science, Cochrane, SinoMed, CNKI, Wanfang Database, CQVIP, and Chinese journals databases between inception and July 2023. Pooled standardized mean differences (SMD) or weighted mean difference (WMD) with 95% confidence intervals (CI) from RCTs evaluating Schirmer's I test (SIT), corneal fluorescein staining score (CFS), tear breakup time (TBUT), DES score (DESS), and Ocular Surface Disease Index (OSDI) were calculated. Sensitivity analysis, Egger's test and Meta-regression analysis were performed for all indicators.

RESULTS

We conducted a Meta-analysis of 10 RCTs that met the inclusion criteria, involving 1796 cases. High-concentrations group significantly improved the outcome of CFS according to random effects modelling (SMD, -3.37; 95%CI, -5.25 to -1.48; P=0.0005). The rest of the results were not statistically significant, including indicators such as SIT, TBUT, DESS and OSDI.

CONCLUSION

For dry eyes with positive corneal staining, a high concentration of HY is recommended, whereas in other cases, a high concentration of HY does not offer a more pronounced advantage over a low concentration of HY in the treatment of dry eyes.

Evaluation of tear film in patients with AIDS without opportunistic ocular infections in the era of COVID-19: A case-control study

PURPOSE

The assessment of tear film and ocular surface conditions in patients with acquired immunodeficiency syndrome (AIDS) has been poorly studied thus far. We aim to assess tear film parameters, ocular surface characteristics, and dry eye disease (DED) symptoms of patients with AIDS who did not undergo highly active antiretroviral treatment (HAART).

METHODS

This case-control study included 154 age-, sex-, and ethnicity-matched healthy controls and patients with AIDS. All participants underwent comprehensive ocular surface assessment and subjective DED symptomology evaluation. Data were collected between March 2022 and July 2022.

RESULTS

HAART-naïve patients with AIDS had a shorter noninvasive tear film breakup time (median 3.76 vs. 8.54 s), thinner tear film lipid layer thickness (median 73.00 vs. 91.00 nm), and lower Schirmer I test values (median 5.00 mm/5 min vs. 12.00 mm/5 min) (all P < 0.001). Moreover, higher corneal fluorescein staining scores (median 1.00 vs. 0.00) and higher upper, lower, and total meibomian gland grades were observed in AIDS patients (all P < 0.05). Negative correlations between the blood viral load and the Ocular Surface Disease Index score ( r = -3.50, P = 0.027) and the Schirmer I test score ( r = -0.374, P = 0.017) were detected in patients with AIDS.

CONCLUSION

Altered tear film status was observed in individuals with HAART-naïve AIDS, even when there were no other ocular symptoms present. Therefore, patients with AIDS should be encouraged to undergo comprehensive ocular surface examinations to detect any subclinical tear film alterations occurring.

New Korean Guidelines for the Diagnosis and Management of Dry Eye Disease

New Korean guidelines for the diagnosis and management of dry eye disease were developed based on literature reviews by the Korean Dry Eye Guideline Establishment Committee, a previous dry eye guideline by Korean Corneal Disease Study Group, a survey of Korean Dry Eye Society (KDES) members, and KDES consensus meetings. The new definition of dry eye was also proposed by KDES regular members. The new definition by the regular members of the KDES is as follows: "Dry eye is a disease of the ocular surface characterized by tear film abnormalities and ocular symptoms." The combination of ocular symptoms and an unstable tear film (tear breakup time <7 seconds) was considered as essential components for the diagnosis of dry eye. Schirmer test and ocular surface staining were considered adjunctive diagnostic criteria. The treatment guidelines consisted of a simplified stepwise approach according to aqueous deficiency dominant, evaporation dominant, and altered tear distribution subtypes. New Korean guidelines can be used as a simple, valid, and accessible tool for the diagnosis and management of dry eye disease in clinical practice.

Sociodemographic and Clinical Predictors of Prolonged Length of Corneal Ulcer Hospitalizations

Importance

The length of stay (LOS) of hospitalizations may be a useful indicator of the burden of disease of corneal ulcers. Identifying variables associated with longer LOS may help to enhance delivery of care for high-risk patients.

Objective

To investigate the sociodemographic, social, and clinical factors associated with LOS in hospitalizations for corneal ulcers in the US.

Design, Setting, and Participants

This was a retrospective cross-sectional study of adult patients (aged >18 years) admitted with a primary diagnosis of corneal ulcer between quarter 4 of 2015 through 2020 and conducted using data from the National Inpatient Sample (NIS). Patients were stratified into 2 even cohorts based on LOS: LOS of 4 days or less and LOS greater than 4 days. Individual-level sociodemographic, social risk factors, and medical comorbidities associated with longer LOS were examined by multivariable regression. Data were analyzed from October 2015 to December 2020.

Exposure

Potential sociodemographics or medical comorbidities at hospital admission.

Main Outcome and Measure

The primary outcome of interest was factors associated with extended length of stay. The hypothesis being tested was formulated during data collection.

Results

A total of 1187 patients (mean [SD] age, 53.5 [20.9] years; 602 female [50.7%]) were included for analysis. The cohort with LOS greater than 4 days had higher total charges than the cohort with LOS of 4 days or less (mean [SD] charges, $79 504 [$86 719] vs $26 474 [$20 743]; P < .001). Sociodemographic variables associated with LOS greater than 4 days were Black race (adjusted odds ratio [aOR], 1.41; 95% CI, 1.03-1.92; P = .03), Medicare insurance (aOR, 1.42; 95% CI, 1.09-1.85; P = .009), and housing insecurity (aOR, 1.99; 95% CI, 1.29-3.06; P = .002). Medical comorbidities associated with LOS greater than 4 days were alcohol use (aOR, 1.50; 95% CI, 1.00-2.26; P = .05), dementia (aOR, 2.35; 95% CI, 1.36-4.07; P = .002), complicated diabetes (aOR, 1.75; 95% CI, 1.21-2.53; P = .003), uncomplicated diabetes (aOR, 1.57; 95% CI, 1.02-2.42; P = .04), drug misuse (aOR, 1.66; 95% CI, 1.08-2.57; P = .02), and legal blindness (aOR, 3.42; 95% CI, 1.19-9.82; P = .02). Based on NIS national estimates, corneal ulcers were estimated to have a direct annual health care expenditure of $35 819 590 in the US.

Conclusion and Relevance

Corneal ulcer hospitalizations represent a significant burden of disease for patients and health care systems. This study highlights sociodemographic and clinical factors that may help clinicians identify high-risk patients vulnerable to complications and morbidity due to corneal ulcers.

Patient barriers and facilitators for making environmental and behavioral modifications for dry eye in the United States

BACKGROUND

Managing dry eye disease (DED) is expensive. Often, prescribed treatments improve clinical signs but not patient-reported symptoms. In large surveys, clinicians and patients ranked environmental and behavioral modifications among the most important DED-related research priorities. Our purpose was to investigate the barriers to and facilitators of use of these modifications by patients with DED in the United States and how their use may be impacted by socioeconomic status (SES).

METHODS

Using Qualtrics, we conducted an anonymous online survey of adults with DED living in the United States in August to September 2022. Patients were identified through the Dry Eye Foundation, Sjögren's Foundation, and a DED clinic in Colorado. We used an established index for classifying respondent SES based on education, household income, and employment. Outcomes included use of environmental and behavioral modifications and barriers to and facilitators of their use.

RESULTS

We included 754 respondents (SES: 382 low, 275 high, and 97 unclear). Most were aged 18 to 49 years (67%), female (68%), and White (76%) and reported dealing with DED for ≤5 years (67%). The most frequent modifications were taking breaks to rest eyes (68%), increasing water intake (68%), and using hot/cold compresses (52%). For these three, the biggest facilitators were as follows: belief that the modification works (27 to 37%), being recommended it (24 to 26%), and ease of use/performance (21 to 32%). Across modifications, the biggest barriers were difficulty of use (55%), lack of family/employer/social/community support (33%), and lack of awareness (32%). The data do not suggest discernible patterns of differences in barriers or facilitators by SES.

CONCLUSIONS

Greater emphasis should be placed on explaining to patients how environmental and behavioral modifications might mitigate DED. Employers and members of patients' support systems should be guided regarding how best to support patients in managing DED symptoms.

A Comprehensive Study on Tear Meniscus Height Inter-Eye Differences in Aqueous Deficient Dry Eye Diagnosis

(1) Background: Dry eye disease (DED) is a chronic ocular surface condition that requires precise diagnostic tools. The present study aimed to investigate the diagnostic potential of the absolute inter-eye difference (|OD-OS|) in tear meniscus height (TMH) for the detection of the presence of aqueous deficient dry eye (ADDE). (2) Methods: A sample of 260 participants with dry eye complaints underwent ocular surface examinations thorough diagnostic assessments based on the Tear Film and Ocular Surface Society guidelines (TFOS DEWS II). Participants were subsequently categorized as No ADDE and ADDE based on TMH. Statistical analyses to determine the optimal TMH|OD-OS| cut-off value in a randomly selected study group (200 participants) were performed, while a separate validation analysis of the cut-off value obtained in a random cross-validation group (60 participants) was also performed. (3) Results: The significant diagnostic capability of TMH|OD-OS| (area under the curve = 0.719 ± 0.036, p < 0.001) was found. The identified cut-off value of 0.033 mm demonstrated reliable specificity (77.6%) and moderate sensitivity (59.1%). Cross-validation confirmed the cut-off value's association with the TFOS DEWS II diagnostic criterion (Cramer's V = 0.354, p = 0.006). (4) Conclusions: The present study provides evidence for the diagnostic potential of TMH|OD-OS| in identifying ADDE. The identified cut-off value enhances the specificity and offers moderate sensitivity, providing an objective tool for clinical decision making.

Dry eye disease in the young: A narrative review

Dry eye disease (DED), a multifactorial ocular disease that significantly impacts quality of life, is most commonly reported in adults. This review describes the prevalence, risk factors, diagnosis and management of DED in children. A literature search, conducted from January 2000-December 2022, identified 54 relevant publications. Using similar diagnostic criteria to those reported in adults, namely standardized questionnaires and evaluation of tear film homeostatic signs, the prevalence of DED in children ranged from 5.5% to 23.1 %. There was limited evidence for the influence of ethnicity in children, however some studies reported an effect of sex in older children. Factors independently associated with DED included digital device use, duration of digital device use, outdoor time and urban living, Rates of DED were higher in children with ocular allergy and underlying systemic diseases. Compared with similar studies in adults, the prevalence of a prior DED diagnosis or a diagnosis based on signs and symptoms was lower in children, but symptoms were commonly reported. Treatment options were similar to those in adults, including lifestyle modifications, blinking, management of lid disease and unpreserved lubricants in mild disease with escalating treatment with severity. Management requires careful exploration of symptoms, medical history and the diagnosis and management of ocular comorbidities such as allergy and anterior blepharitis. Appropriately powered population-based studies are required to understand the prevalence of and risk factors for DED in children. Development of age-appropriate thresholds for signs and symptoms of DED would support better diagnosis of disease and understanding of natural history.

Prolonged facemask wearing among hospital workers and dry eye - a mixed-methods study

BACKGROUND

Prolonged facemask wearing may have negatively affected essential workers with dry eye. We conducted a mixed-methods study to examine and understand the associations of the ocular surface, periocular environment, and dry eye-related symptoms among hospital workers across the job spectrum with prolonged facemask use.

METHODS

We recruited clinical and non-clinical hospital workers with self-reported symptoms of dry eye and prolonged facemask use. We measured symptoms using the 5-item Dry Eye Questionnaire and the Ocular Surface Disease Index (OSDI). Objective ocular signs included corneal and conjunctival staining, fluorescein tear break up time (TBUT), meibography, tear film interferometry, and periocular humidity. We compared symptoms and signs across levels of periocular humidity, dry eye severity, facemask type, and job type. Participants with moderate or severe dry eye symptoms (OSDI > = 23) were invited for a semi-structured, one-on-one interview.

RESULTS

We enrolled 20 clinical and 21 non-clinical hospital workers: 27% were 40 years or older, 76% were female, 29% reported a race other than White, and 20% were Hispanic. Seventeen individuals participated in the semi-structured interviews. From the quantitative analyses, we found that 90% of participants reported worsened severity of dry eye at work due to facemasks. Although wearing facemasks resulted in higher periocular humidity levels compared with not wearing facemasks, 66% participants reported increased airflow over their eyes. Findings from the qualitative interviews supported the finding that use of facemasks worsened dry eye symptoms, especially when facemasks were not fitted around the nose. The data did not suggest that non-clinical hospital workers experienced a greater impact of dry eye than clinical workers.

CONCLUSIONS

Healthcare providers and patients with dry eye should be educated about the discomfort and the ocular surface health risks associated with inadequately fitted facemasks. Wearing a fitted facemask with a pliable nose wire appears to mitigate the upward airflow.

TFOS Lifestyle Report Executive Summary: A Lifestyle Epidemic - Ocular Surface Disease

The Tear Film & Ocular Surface Society (TFOS) Workshop entitled 'A Lifestyle Epidemic: Ocular Surface Disease' was a global initiative undertaken to establish the direct and indirect impacts of everyday lifestyle choices and challenges on ocular surface health. This article presents an executive summary of the evidence-based conclusions and recommendations of the 10-part TFOS Lifestyle Workshop report. Lifestyle factors described within the report include contact lenses, cosmetics, digital environment, elective medications and procedures, environmental conditions, lifestyle challenges, nutrition, and societal challenges. For each topic area, the current literature was summarized and appraised in a narrative-style review and the answer to a key topic-specific question was sought using systematic review methodology. The TFOS Lifestyle Workshop report was published in its entirety in the April 2023 and July 2023 issues of The Ocular Surface journal. Links to downloadable versions of the document and supplementary material, including report translations, are available on the TFOS website: http://www.TearFilm.org.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

TFOS Lifestyle: Impact of contact lenses on the ocular surface

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

Comparing Tear Film Viscosity between Sjögren and Non-Sjögren Dry Eye Disease

This study aimed to compare tear film viscosity (TFV) in Sjögren and non-Sjögren dry eye diseases (DEDs). This was a cross-sectional observational study. A total of 68 DED patients were enrolled, including 32 patients with Sjögren syndrome (SS) and 36 without SS. TFV was assessed by a tear film analyzer and determined by the momentary moving speed (MMS; MMS (t) = α × t-β, t = time (s)) with its power-law fitting-derived parameters (α and β). Among the four indices of TFV (MMS (0.1 s), MMS (2.0 s), α, and β), the SS-DED patients had significantly lower MMS (0.1 s) (p = 2.01 × 10-5), α (p = 0.0375), and β (p = 0.0076). The SS-DED group also had significantly higher OSDI, lower central and nasal tear meniscus height (TMH), and higher OSS. MMS (0.1 s) was significantly correlated with nasal TMH and OSS (ρ = 0.2520, p = 0.0381 in nasal TMH; ρ = -0.3487, p = 0.0036 in OSS). Index β was not correlated with any non-TFV tests. In conclusion, MMS (0.1 s), α, and β are promising TFV indices in distinguishing SS-DED from non-SS-DED patients early. Among these TFV indices, lower MMS is the best alternative clue for detecting SS-DED.