The Epidemiology of Dry Eye Disease: Report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007)

Rodent models for dry eye syndrome (DES)

Dry eye syndrome (DES) is a range of ophthalmic conditions characterized by compromised tear film homeostasis, resulting from various pathological factors and primarily manifesting as ocular discomfort and impaired ocular surface integrity. With the rise in screen time due to modern lifestyles, the prevalence of DES is increasing annually, posing a significant global public health challenge. Pathophysiologically, DES involves damage to the lacrimal functional unit (LFU), including the lacrimal glands, meibomian glands, and corneoconjunctival epithelium, highlighting its multifactorial etiology. Current treatments mainly focus on artificial tears for moisture replacement and anti-inflammatory therapies, but both are limited. Consequently, animal models are crucial for understanding the complex pathological mechanisms of DES and identifying potential therapeutic agents. Rodent eyes, with their structural and physiological similarities to human eyes and cost-effectiveness, have become widely used in DES research. This manuscript reviews the current understanding of DES pathogenesis and rodent models, discussing their strengths, weaknesses, and relevant genetic models. The aim is to furnish critical insights and provide a scholarly resource to propel future investigative endeavors into the pathogenesis of and therapy for DES.

Pre-wetted modified Schirmer's tear test to determine lacrimal tear-production rate from severe lacrimal-gland dysfunction patients

SIGNIFICANCE

To determine basal tear-production rates from low tear-producing patients, we present a prewetted modified Schirmer's tear test (PW-MSTT). The improved method is an extension of the MSTT that provides a reliable method to investigate the relation between dry-eye symptoms and basal tear production rates.

PURPOSE

The MSTT quantifies basal tear-production rates from patients. However, the existing test does not allow measurement of basal tear-production rates from patients that do not wet past the 5-mm mark on the Schirmer strip within 5 minutes. We extended the MSTT with a prewetting technique to allow quantification of basal tear-production rates from patients that do not adequately wet the Schirmer strip within 5 minutes of strip insertion.

METHODS

An in-vitro study was conducted with sheathed Schirmer strips to determine the volume of sterile nonpreservative saline solution necessary to prewet the Schirmer strip before insertion. This assessment determined that 1.6 µL of prewetting saline wets the Schirmer strip to 5.2 mm of the Schirmer strip, enough to allow basal tear production rate determination from subjects that do not adequately wet the Schirmer strip out to the 5-mm mark. Then, a clinical study was conducted with sheathed Schirmer strips with the prewetting technique to determine the basal tear-production rate from subjects that could not wet sufficiently to determine their basal tear-production rate.

RESULTS

Eleven subjects completed the study; the basal tear production rates from these low tear-producing subjects were determined. The mean (SD) of the measured basal tear-production rate was 0.40 µL/min (0.28 µL/min) compared with normal subjects at 1.19 µL/min.

CONCLUSIONS

The developed PW-MSTT successfully quantifies basal tear production rates from subjects that do not adequately wet the Schirmer strip without the new prewetting technique. The determined basal tear-production rate from these low tear-producing subjects was three times less than that of those from a previous study where the subjects could adequately wet the Schirmer strip past the 5-mm line. Our improved methodology for low tear-producing patients sheds insight into how basal tear production rate is related to aqueous-deficient dry-eye symptoms.

The prevalence of dry eye disease symptoms and its association with screen time in young adults aged 21-30 years

PURPOSE

To investigate the correlation between dry eye disease (DED) symptoms and academic performance in young adults aged 21-30 years, as well as to determine the relationship between screen time and DED symptoms.

METHODS

A total of 454 young adults, between 21 and 30 years of age, were initially enrolled in the study. Data collected included age, sex, grade point average (GPA), hours of contact lens wear, degree of compliance with the 20-20-20 rule, response to the Ocular Surface Disease Index (OSDI) questionnaire, as well as screen time for studying and engaging in social media activities. Spearman correlation analysis was conducted to investigate the relationship between DED symptoms and academic performance, screen time and contact lens usage.

RESULTS

A total of 445 participants were included in the analysis, with 99.3% (n = 442) exhibiting DED symptoms (OSDI ≥13). The mean (standard deviation) OSDI score was 76.91 (17.89). Additionally, only 17.0% of participants adhered to the recommended 20-20-20 rule during screen usage. Mean daily screen time was 9.84 (3.73) h, with 2.97 (2.34) h for social media and 6.93 (3.48) h for study. OSDI scores were significantly correlated with study screen time (rs = 0.12, p = 0.01) and social media usage (rs = 0.13, p = 0.01), but not with GPA (rs = -0.07, p = 0.16) or contact lens daily wearing time (rs = 0.05, p = 0.43).

CONCLUSIONS

The prevalence of DED symptoms was found to be high amongst young adults. This study revealed a significant association between the duration of screen time and DED symptoms in this population. Prolonged screen exposure, both for academic purposes and social media engagement, was linked with more severe manifestations of DED. Notably, no significant correlation was observed between academic performance and DED symptoms in young adults.

The repeatability of tests for dry eye signs and symptoms in the dry eye assessment and management (DREAM) study

PURPOSE

To assess the repeatability of measures for dry eye disease (DED) symptoms and signs in the DREAM study.

METHODS

At screening and baseline visits approximately 2 weeks apart, participants were assessed for symptoms by Ocular Surface Disease Index (OSDI) and Brief Ocular Discomfort Index (BODI), and signs by the same physician in the same order: tear break-up time (TBUT), corneal staining, conjunctival staining, Meibomian gland evaluation, and the Schirmer test. The repeatability of DED symptoms and signs was assessed by interclass correlation coefficient (ICC), 95 % limits of agreement, and the percent of eyes with inter-visit difference above the clinically significant threshold.

RESULTS

Among 1046 eyes (523 participants), ICC for signs ranged from 0.53 (TBUT) to 0.73 (corneal staining). A substantial percentage of eyes showed clinically significant inter-visit differences: ≥2 points in 17.8 % of eyes for conjunctival staining; ≥3 points in 18.8 % for corneal staining; >2 s in 14.1 % for TBUT; ≥5 mm/5 min in 29.9 % for the Schirmer test, and ≥ 2 points in 27.5 % for Meibomian gland plugging and lid secretion. The OSDI and BODI had ICC of 0.64 and 0.63 respectively, and nearly 40 % of participants had inter-visit score differences ≥ 10 points.

CONCLUSION

In DREAM participants with moderate-to-severe DED, DED signs and symptoms had moderate repeatability, with ocular surface staining scores being the most repeatable and TBUT the least repeatable. A notable percentage of participants had inter-visit differences above the clinically meaningful threshold. These test-retest variabilities in DED signs and symptoms should be considered for designing clinical trials and monitoring disease progression.

Comparison of keratometry assessment between IOLMaster and Pentacam in dry eyes

BACKGROUND

To compare the keratometry measurements between IOLMaster and Pentacam in dry eyes.

METHODS

A total of 122 eyes of 95 age-related cataract patients with dry eye disease were enrolled in this study. Keratometry measurements including flat and steep keratometry (K), mean keratometry, axis of the flat K, astigmatism of anterior corneal surface (A-ACS) were obtained using IOLMaster and Pentacam. A second series of examinations were performed 1 min after instillation of artificial tears. Values of keratometry measured by two devices were compared both before and after using artificial tears. Changes of the above parameters in each device were also analyzed.

RESULTS

The mean flat K of IOLMaster was significantly lower than Pentacam. A-ACS was significantly larger in IOLMaster than in Pentacam, with a mean discrepancy of 0.46 D and an upper limit of 95 % LoA of 1.48 D. The 95 % LoA for flat K axis also exceeded the clinically relevant margin. Keratometry and A-ACS measurements were significantly modified after instillation of artificial tears. None of the above parameters showed significant difference between two devices except for A-ACS, with the mean difference decreased to 0.17 D with 95 % LoA of -0.20 to 0.54 D. Intra device comparison showed that changes of A-ACS and flat K axis measured with IOLMaster were greater than those measured with Pentacam.

CONCLUSION

Dry eye has significantly greater impact on keratometry measured with IOLMaster than with Pentacam. For cases with A-ACS between the two devices over 0.5 D, artificial tears are recommended before performing biometry.

Melatonin Alleviates Age-Related Lacrimal Gland Dysfunction Via SIRT-1/NLRP3 Pathway

Purpose

As a consequence of the natural aging process, the lacrimal glands may become dysfunctional. The present study aimed to investigate the potential role of melatonin (MLT) in the alleviation of age-related lacrimal gland dysfunction and to elucidate the underlying mechanism.

Methods

In this study, lacrimal glands of 2-month-old, 18-month-old, and MLT intraperitoneally injected 18-month-old mice were obtained for immunofluorescence, immunohistochemistry experiments, and Western blotting to detect inflammatory factors and AQP5 expression, and for electron microscopy to detect mitochondrial structure and dense granules. Lacrimal glands from 18-month-old mice were taken for cell culture, and PCR and Western blotting were performed to detect the signaling pathways in which MLT acts. In addition, the human lacrimal gland explant cultures were performed to validate the role of MLT and the SIRT-1/NLRP3 signaling pathways.

Results

In this study, we discovered that aging increased the inflammatory response, decreased secretory function, and led to mitochondrial dysregulation in lacrimal gland. Compared with 2-month-old mice, SIRT-1/3/6 gene transcript levels were significantly decreased in 18-month-old mice. MLT reduced inflammatory factors (IL-1β, IL-6, and TNF-α) and increased AQP5 expression via the SIRT-1/NLRP3 signaling pathway in aged lacrimal gland of human and mouse. Furthermore, MLT restored mitochondrial structure and increased dense granules in aged mouse lacrimal gland. In explants of human lacrimal gland, MLT relieved fibrosis.

Conclusions

The present study demonstrated that MLT alleviates age-related lacrimal dysfunction in mice and humans via the SIRT-1/NLRP3 pathway. MLT alleviated the inflammatory response and the decline in the secretory function of the aged lacrimal gland.

Topical neurokinin-1 receptor antagonism ameliorates ocular pain and prevents corneal nerve degeneration in an animal model of dry eye disease

Introduction

Ocular pain is a common complaint to eye care providers, associated with a variety of ocular conditions, among which dry eye disease (DED) is affecting millions of people worldwide. Despite being highly prevalent, ocular pain is not managed adequately in the clinic.

Objectives

The aim of this study was to investigate the analgesic potential of neurokinin-1 receptor (NK1R) antagonism in DED.

Methods

Dry eye disease was induced in mice, and an NK1R antagonist L-733,060 was topically administered twice daily throughout the study for 14 days. Hyperalgesia and allodynia were assessed using the eye-wiping test and palpebral ratio measurements. Corneas were collected for measuring substance P (SP) levels by enzyme-linked immunosorbent assay (ELISA) and imaging nerves by immunostaining. Trigeminal ganglions (TG) were collected to determine SP levels by ELISA and transient receptor potential cation channel subfamily V member 1 (TRPV1), transient receptor potential cation channel subfamily M (melastatin) member 8, c-Fos, and activating transcription factor 3 (ATF3) mRNA levels by real-time polymerase chain reaction.

Results

Treating DED mice with L-733,060 resulted in a significant reduction in eye wipe behavior, a significant increase in palpebral ratio, and significant decreases in SP levels in both the cornea and TG compared with the vehicle-treated group. In addition, NK1R antagonist treatment significantly suppressed the upregulation of TRPV1, ATF3, and c-Fos and prevented corneal nerve loss.

Conclusion

Neurokinin-1 receptor antagonism effectively reduced ocular nociception, decreased neuronal activation, and preserved corneal nerves in mice with DED. These findings suggest that blockade of SP signaling pathway is a promising therapeutic strategy for managing DED pain.

Longitudinal Analysis of Tear Cytokine Ratios in Association with Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management (DREAM) Study

PURPOSE

To extend cross-sectional data on cytokine ratios (CRs) in dry eye disease (DED) signs by investigating longitudinal change in pro- to anti-inflammatory CRs and associations with change in DED signs and symptoms.

METHODS

Secondary analysis of fifty-four subjects [mean age 57.3 (SD 13.2) years, 85.2% female; 68.5% white] with ≥ 4 uL pooled tear volumes at months 0, 6, and 12. Pro-inflammatory (IL-1b, IL-6, IL-8, IL-17A, IFN-g, and TNF-a) to anti-inflammatory (IL-6, IL-10) cytokine ratios (CR) were calculated. DED signs (corneal and conjunctival staining scores, tear break-up time, Schirmer test, Meibomian gland plugging, tear osmolarity, composite sign severity score) and symptoms [Ocular Surface Disease Index (OSDI)] were measured. Changes over time in DED signs, symptoms, and CRs were evaluated using longitudinal models. Correlations between changes in CR and changes in DED signs and symptoms were evaluated using Spearman correlation coefficients (rho).

RESULTS

DED signs which improved over time (p < 0.001) included corneal and conjunctival staining score, tear break-up time, tear osmolarity, and composite sign severity score. Using IL-10 as anti-inflammatory, changes in corneal and conjunctival staining and composite severity score significantly correlated with changes in pro- to anti-inflammatory CRs from month 0 to 6 (|rho|: 0.29-0.45, p: 0.003-0.04) but not between month 0 to 12 (|rho|: 0.01 to 0.24, all p > 0.08). DED symptoms decreased across one year (p < = 0.001) for all OSDI measures; these changes did not correlate with changes in CRs (|rho|: 0.00 to 0.29, all p > 0.04).

CONCLUSIONS

Improvement in some DED signs across one year correlated weakly with decreases in pro- to anti-inflammatory CRs, in alignment with the understanding of DED as inflammatory. CRs may provide greater insight than absolute tear cytokine concentrations as possible DED biomarkers. Additional studies that provide standardized clinical information and tear collection and analysis are needed to validate CRs in DED.

Is There a Difference Between Seropositive and Seronegative Sjögren Disease Dry Eye?

PURPOSE

The study aims to compare dry eye disease (DED) prevalence and severity between seropositive and seronegative Sjögren disease (SjD).

METHODS

Prospective, consecutive, comparative cross-sectional cohort study. A total of 160 eyes of 80 patients with SjD by The American College of Rheumatology and the European League Against Rheumatism 2016 criteria were included: 55 seropositive and 25 seronegative SjD. Associated SjD was excluded. Patients had dry eye tests performed. Generalized estimating equations were used to account for intereye correlation of the same participant.

RESULTS

Mean age was 52.2 ± 12.7, 96.3% were women, no differences were observed between groups (P > 0.05). Seronegative SjD had positive minor salivary gland biopsy more often (100% vs. 82%, P = 0.024), but with lower focus score (2.0 ± 1.2 vs. 4.1 ± 3.5, P = 0.006) than seropositive SjD group. DED prevalence was similar in seropositive and seronegative SjD (92.7% and 84%; P = 0.088). Only noninvasive break-up time (NIBUT) average was significantly reduced in seropositive SjD (6.6 ± 3.2 vs. 8.8 ± 2.4, P = 0.011), and the rest of the evaluated DED tests were not significant. In the seropositive group, nonstatistically significant trends toward more severe DED signs, including matrix metalloproteinase-9, osmolarity, Schirmer I without anesthesia, fluorescein tear break-up time, NIBUT first, and Sicca Ocular Staining Score, were observed. Both groups were highly symptomatic in ocular surface disease index score (43 ± 23 vs. 46 ± 30, P = 0.779) and had a reduction in quality of life in National Eye Institute visual health questionnaire-25 test (72 ± 21 vs. 70 ± 24, P = 0.650).

CONCLUSIONS

Patients with seropositive SjD showed significantly reduced NIBUT and a trend of more severe DED signs. Patients with seronegative and seropositive SjD were similarly highly symptomatic, experienced important reductions in vision-related quality of life, and had similar DED prevalence.

Association between traffic-related air pollution and risk of outpatient visits for dry eye disease in a megacity along the subtropical coast in South China

BACKGROUND

Traffic-related air pollution especially in highly socioeconomically developed megacity is usually considered as a severe problem leading to inevitable adverse health outcomes. This study aimed to investigate the associations between traffic-related air pollutants with risk of dry eye disease (DED) outpatient visits in a megacity (Guangzhou) along the subtropical coast in South China.

METHODS

Daily data on DED outpatient visits and environmental variables from 1 January 2014 to 31 December 2020 in Guangzhou were obtained. A time-series study using a quasi-Poisson generalized linear model (GLM) combined with distributed lag non-linear model (DLNM) was adopted. Subgroup analyses stratified by age, gender, and season were conducted.

RESULTS

Totally, 27, 828 DED cases were identified during the study period including 2557 days. Daily number of outpatient visits for DED ranged from 0 to 41. An increase of 10 μg/m3 in PM2.5, NO2 and SO2 concentration was associated with 3.1%, 5.9% and 17.4% increase in the risk of DED outpatient visits, respectively (RRPM2.5 = 1.031, 95%CI: 1.004-1.059, lag 0-11 day; RRNO2 = 1.059, 95% CI: 1.027-1.092, lag0-14 day; RRSO2 = 1.174, 95% CI: 1.036-1.330, lag0-13 day). Subgroup analyses indicated that the effects of PM2.5 exposure on the risk of DED outpatient visits remained significant in aged < 60 years (RR max = 1.008, 95% CI: 1.003-1.013, lag0 day) and the effects of SO2 exposure on the DED outpatient visits risk remained significant in the females (RR max = 1.025, 95% CI: 1.006-1.044, lag0 day). The associations of PM2.5 (RR = 1.010, 95% CI: 1.003-1.016, lag0 day) and SO2 (RR = 1.030, 95% CI: 1.003-1.058, lag14 day) exposure with DED outpatient visits risk remained significant in warm seasons, whereas NO2 (RR = 1.006, 95% CI: 1.002-1.009, lag14 day) exposure was significantly associated with DED outpatient visits in cold seasons. The associations of PM2.5 (first visit, RR = 1.006, 95% CI: 1.001-1.011, lag0 day; re-visit, RR = 1.002, 95% CI: 1.000-1.005, lag6 day), NO2 (first visit, RR = 1.006, 95% CI: 1.001-1.012, lag0 day; re-visit, RR = 1.007, 95% CI: 1.002-1.012, lag0 day), and SO2 (first visit, RR = 1.023, 95% CI: 1.002-1.044, lag0 day; re-visit, RR = 1.023, 95% CI: 1.000-1.045, lag0 day) exposure with risk of DED outpatient visits were significant for both first- and re-visits.

CONCLUSIONS

Our study revealed that short-term exposure to PM2.5, NO2 and SO2 were positively associated with risk of DED outpatient visits, especially for the youngers, females and during warm seasons, providing evidence for making public health policy to improve life quality in developed megacity.

Real-world analysis of medications inducing meibomian gland dysfunction: based on the FDA adverse event reporting system database

BACKGROUND

Dry eye syndrome (DES) significantly affects quality of life. Meibomian Gland Dysfunction (MGD) is a primary contributor to DES and may be drug-induced.

RESEARCH DESIGN AND METHODS

This study analyzed data from the FDA Adverse Event Reporting System (FAERS) between January 2004 and September 2023 using the Ratio of Odds Ratios (ROR) and Proportional Reporting Ratio (PRR) to detect potential drug-induced MGD signals. Drugs were categorized by therapeutic class.

RESULTS

Among 289 MGD cases, the average patient age was 51.69 years, with 65.44% female. MGD reports have increased over time, peaking in 2023, primarily from the United States and Europe. Of 148 drugs, nine showed significant associations with MGD, including those in ophthalmology, oncology, immunomodulation, dermatology, and the urogenital system.

CONCLUSION

This real-world study identifies drugs potentially linked to MGD, offering valuable insights for drug safety surveillance. These findings support the development of pharmacovigilance strategies and optimized clinical practice to mitigate ocular risks.

A Novel Rabbit Model of Meibomian Gland Dysfunction-Induced Dry Eye

Purpose

The objective of this three-phase study was to develop a model of mild to moderate evaporative dry eye to be used to evaluate tear film stability endpoints during product development.

Methods

Rabbits were sedated prior to ophthalmic cautery of meibomian gland orifices. The orifices of eyelid meibomian glands were half-cauterized (to yield obstruction of every other meibomian gland orifices), fully cauterized (to yield obstruction of all meibomian gland orifices), or untreated. The primary outcome measures were model repeatability, tear film break-up time (TBUT), non-invasive tear break-up time (NIBUT), and model confirmation with daily artificial tears. Other examinations included Draize score, tear production, fluorescein staining, eschar, and histopathology.

Results

Cauterization was well tolerated in all phases. In phase I, TBUT was significantly decreased compared to baseline on days 14, 21, 28, and 35 in fully cauterized meibomian gland orifices but not in half-cauterized meibomian gland orifices. In phase II, both NIBUT and TBUT were similarly and significantly reduced in the fully cauterized meibomian gland orifices compared to the control eyes on days 7, 9, 14, and 28. In the confirmation phase, the administration of eye drops significantly improved NIBUT over the course of the study.

Conclusions

A rabbit model of dry eye was successfully and safely created through the obstruction of meibomian gland orifices by cautery, which yielded a significant reduction in tear film stability. A quantifiable benefit of artificial tears relative to untreated control was demonstrated within the model.

Translational Relevance

When the model is deployed, the utility and efficacy of therapeutic formulations can be evaluated.

Evaluation of the Performance of an Ocular Surface Modulator Containing ST-Lysyal Versus Hyaluronic Acid Eyedrops in Patients with Dry Eye Disease: A Pilot Study

INTRODUCTION

Dry eye disease (DED) is a multifactorial condition of the ocular surface, primarily treated with tear substitutes, which do not fully restore natural tear functions. In this pilot study, we tested the hypothesis that T-Lysyal (T-Lys) improves symptoms and signs in patients with DED. Additionally, we provide a literature overview on the effects of T-Lys in ophthalmology and non-ophthalmology conditions to elucidate its mechanisms of action.

METHODS

A double-masked, randomized pilot study was conducted in patients with DED treated with T-Lys or hyaluronic acid (HA) 0.2% combined with tamarind seeds polysaccharide (control group) for 2 months. Inclusion criteria were a diagnosis of DED with symptoms lasting ≥ 6 months, Symptom Assessment in Dry Eye (SANDE) score ≥ 30, and at least one of the following: fluorescein staining of the cornea (score ≥ 3, NEI scale), conjunctival staining (Lissamine Green, score ≥ 3), or tear breakup time (T-BUT) ≤ 10 s. Data from the right eye were used for statistical analysis. A PubMed literature search of T-Lys studies was also performed without publication year restrictions.

RESULTS

Twelve patients in the T-Lys group and 15 in the control group completed the study (mean age 67 ± 11 years). T-Lys treatment resulted in significant improvements from baseline (V0) to 2 months (V2) in symptoms assessed by visual analogue scale (T-Lys: 4.58 ± 2.57 mm at V0, 2.92 ± 1.38 mm at V2, p < 0.05; control: 5.13 ± 2.29 mm at V0, 5.3 ± 2.4 mm at V2), T-BUT (T-Lys: 2.58 ± 1.31 s at V0, 3.58 ± 1.37 s at V2, p < 0.05; control: 3.07 ± 1.43 s at V0, 3 ± 1.13 s at V2), and corneal staining (T-Lys: 2.16 ± 4.17 at V0, 1.41 ± 3.70 at V2, p < 0.05; control: 1.4 ± 2.19 at V0, 1.4 ± 2.16 at V2). No adverse events were reported. Literature findings supported T-Lys's efficacy in managing both ophthalmology and non-ophthalmology conditions.

CONCLUSION

This study provides the first clinical evidence of T-Lys efficacy in patients with DED, supporting preclinical data and highlighting its potential as a promising ocular surface modulator.

TRIAL REGISTRATION

The study was registered in the ISRCTN registry for Clinical Studies with no. 13587929.

AZR-MD-001 0.5% selenium sulfide ophthalmic ointment for the treatment of contact lens discomfort: A vehicle-controlled, randomized, clinical trial

BACKGROUND

Contact lens discomfort (CLD) is a common problem for CL wearers, and patients with CLD often have changes in meibomian gland function and structure. In a Phase 2 trial AZR-MD-001 0.5% (AZR) ophthalmic ointment improved meibomian gland dysfunction (MGD) in non-lens wearers. The current study evaluated the efficacy and safety of AZR in participants with CLD and concomitant MGD.

METHODS

Adults with CLD (Contact Lens Dry Eye Questionnaire-8 >12, range 0-37) and MGD (Meibomian Gland Secretion Score [MGS] ≤12, range 0-45) were randomized (1:1) to AZR:vehicle applied twice-weekly in a three-month multicenter, prospective, double-masked study. Endpoints included difference in change from baseline (CFB) in the number of Meibomian Glands Yielding Liquid Secretion (MGYLS), MGS, the ability to wear their lenses as long as desired, and safety.

RESULTS

At Month 3, AZR (n = 34) significantly increased the MGYLS and MGS versus vehicle (n = 33), with least squares mean difference (LSMD) CFB in MGYLS of 5.0 (SE = 0.47) for AZR and 1.6 (0.45) for vehicle, P < 0.0001; MGS of 13.8 (SE = 0.67) for AZR and 3.8 (SE = 0.68) for vehicle, P < 0.0001. Significantly more participants treated with AZR were able to wear lenses as long as desired (43% vs. 6%, P = 0.0023). The most common treatment-emergent adverse event (TEAE) was eye irritation (61.8% AZR; 0% vehicle). All TEAEs related to treatment were mild/moderate, transient, and did not result in discontinuation.

CONCLUSION

AZR-MD-001 0.5% significantly improved MGD signs and hours of comfortable CL wear, demonstrating good efficacy, safety, and tolerability in those with CLD.

Mental burden of ocular surface discomfort

OBJECTIVE

This research investigates the associations between Dry Eye Disease (DED), pain perception, and mental health, focusing on how neuropathic pain influences treatment efficacy and patients' quality of life.

METHODS AND RESULTS

The study delves into the complexity of DED by assessing the correlation between ocular pain, depression, PTSD, and systemic pain conditions. It highlights the role of chronic neuropathic pain in DED and the nociceptive hypothesis, which suggests that psychological stress can exacerbate DED symptoms. Additionally, it explores diagnostic and management strategies for DED, emphasizing the importance of considering psychological aspects to improve patient care.

CONCLUSIONS

The intricate nature of DED, closely linked to mental health issues, requires a comprehensive diagnostic and therapeutic approach. Addressing neuropathic pain and psychological factors is crucial for effective DED management. Future efforts should focus on developing specific interventions targeting DED's physical and emotional impacts to enhance overall patient well-being.

Comparing Patients' Perceptions of Dry Eye Disease Between Spanish- and English-Speaking Patients in the United States

PURPOSE

It is well-known that patients' perceptions of their disease can impact management strategies and disease outcomes. Limited knowledge exists on such perceptions in dry eye disease (DED) and the role of language in these perceptions. Herein, we compared the perceptions about DED between Spanish- and English-speaking patients.

METHODS

This cross-sectional study included 146 patients with DED who underwent ophthalmic evaluation and completed questionnaires assessing their perceptions of DED on a 10-point scale during their routine appointments. Perceptions included opinions on the level of satisfaction with understanding of DED, ease of following doctor's advice, effectiveness of treatment, satisfaction with DED care, and outlook on DED. Perceptions were categorized as low (scores 0-2), moderate (scores 3-7), and high (scores 8-10). The percentage of patients with high perception scores were then compared between Spanish- and English-speaking patients.

RESULTS

There were 48 Spanish speakers and 98 English speakers. Overall, high scores of DED perceptions were identified in 47.9% for satisfaction with the level of understanding of DED, 72.6% for ease of following doctor's advice, 52.1% for helpfulness of DED treatment, 64.4% for satisfaction with DED care, and 52.1% for optimistic outlook on DED. High scores for satisfaction with the level of understanding of DED were significantly lower in Spanish speakers (27.1%) than English speakers (58.2%, p < .001). No significant differences were observed in other perceptions between Spanish- and English-speaking participants.

CONCLUSIONS

Spanish-speaking subjects reported lower satisfaction with their understanding of DED than English speakers. Clinicians should provide health services and educational materials in the patient's preferred language to minimize barriers to understanding their disease.

JAK1, SKI, ZBTB16 as potential biomarkers mediate the inflammatory response in keratoconjunctivitis sicca

Keratoconjunctivitis sicca (KCS) is an ocular condition characterized by insufficient tear production and inflammatory irritation, with Sjögren's syndrome (SS) being a major causative factor. This study aimed to extract patient transcriptomic data from the GEO database to identify signature genes associated with the diagnosis and treatment of KCS and the expression of three key genes were experimentally verified. We performed a difference analysis on the SS patient dataset and performed a Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis on the resulting genes. Additionally, a Weighted Gene Co-expression Network Analysis (WGCNA) was constructed. Machine learning techniques were employed to analyze the most strongly correlated gene modules with SS traits. These findings were further validated using KCS immune-correlation microarrays as a validation set. The correlation of the three identified genes with 22 immune cells was assessed through immune infiltration analysis. Subsequently, a rat model of desiccated keratoconjunctivitis was established, and the modeling situation and expression of characteristic genes were analyzed at the morphological, tissue, and molecular levels. Bioinformatic prediction revealed that the expression of JAK1, SKI, ZBTB16 not only differed in the machine learning validation set, but also correlated with some immune cells in the immune infiltration analysis. The results of animal experiments showed that the transcription and expression levels of these three genes were significantly different in rat KCS tissues and normal tissues, and there were also differences in the expression of JAK1 and SKI in rat peripheral blood, as well as significant up-regulation of the expression of related inflammatory factors in KCS tissues. Through bioinformatics prediction and animal experimental validation, this study identified three differentially expressed genes in SS mediated KCS patients, which provide new potential biological targets for the diagnosis and treatment of KCS.

Evaluating the Effect of Image Enhancement on Diagnostic Reliability in Dry Eye Disease Using a Portable Imaging Device

BACKGROUND

This study aimed to evaluate the impact of image enhancement techniques on the interobserver reliability of tear break-up time (TBUT), tear meniscus height (TMH), corneal fluorescein staining (CFS) scoring, and conjunctivochalasis detection using the Smart Eye Camera (SEC), a portable device for anterior segment examination.

METHODS

A retrospective analysis was conducted on video recordings captured by the SEC from 46 patients with dry eye disease (DED). Separate sets of images were created for each level of enhancement: unenhanced (G0), mildly enhanced (G3), and strongly enhanced (G7). These sets were not intermixed, ensuring that each enhancement level was assessed independently. Three observers-two DED specialists and one general ophthalmologist-assessed TBUT, TMH, CFS scores, and conjunctivochalasis. Interobserver reliability was evaluated using intraclass correlation coefficients (ICCs) for each image set.

RESULTS

Interobserver reliability for CFS scores significantly improved with G3, yielding an ICC of 0.8413. In contrast, G7 improved reliability for TBUT measurements (ICC = 0.7381), but led to a notable decrease in reliability for both CFS scoring (ICC = 0.2259) and conjunctivochalasis detection (ICC = 0.0786). Furthermore, the assessment of TMH demonstrated a progressive decline in accuracy with increasing levels of image enhancement.

CONCLUSIONS

Image enhancement using the SEC improved the diagnostic consistency of dry eye specialists and general ophthalmologists, especially for TBUT and CFS assessments. However, excessive enhancement may obscure key diagnostic features, indicating the need for careful optimization of image processing techniques depending on the diagnostic focus.

PINK1/Parkin-Mediated Mitophagy Ameliorates Mitochondrial Dysfunction in Lacrimal Gland Acinar Cells During Aging

Purpose

Aging alters the function of the lacrimal gland and disrupts the balance of the microenvironment on the ocular surface, eventually leading to aqueous-tear-deficient dry eye. Mitophagy has been reported to play an important role in aging, but the underlying mechanism remains unclear.

Methods

The young (6 weeks) and middle-aged (12 months) male C57BL/6J mice were used in this study, and mitophagy agonist rapamycin and inhibitor Mdivi-1 were used in in vivo experiments. Hematoxylin and eosin, Masson, Oil Red O, and reactive oxygen species (ROS) staining were used to detect histological changes and lipids in lacrimal gland. Changes in the expression of proteins were identified by Western blotting of lacrimal gland lysates. Transmission electron microscopy and immunofluorescence staining were used to assess mitophagy. The single-cell RNA sequencing (scRNA-seq) and bioinformatics analyses were used to detect transcription signature changes during aging.

Results

In this study, we discovered that aging increased oxidative stress, which increased apoptosis, and generated ROS in acinar epithelial cells. Furthermore, activation of PINK1/Parkin-mediated mitophagy by rapamycin reduced lacrimal gland ROS concentrations and prevented aging-induced apoptosis of acinar cells, thereby causing histological alterations, microstructural degradation, and increasing tear secretion associated with ROS accumulation. By contrast, Mdivi-1 aggregates mitochondrial function and thereafter leads to lacrimal gland function impairment by inhibiting mitochondrial fission and giving rise to mitophagy.

Conclusions

Overall, our findings suggested that aging could impair mitochondrial function of acinar cells, and age-related alterations may be treated with therapeutic approaches that enhance mitophagy while maintaining mitochondrial function.

Utilising Narrative Medicine to Identify Key Factors Affecting Quality of Life in Dry Eye Disease: An Italian Multicentre Study

INTRODUCTION

Despite an improved understanding of its pathogenesis, dry eye disease (DED) remains relatively underestimated and its treatment challenging. A better alignment between the clinical evaluation and the patient self-assessment also requires capturing the whole patient experience of DED. This project aimed to unveil this experience through narrative medicine (NM).

METHODS

The project involved 38 expert centres in Italy and one in San Marino, targeting adult patients with DED, their informal caregivers and their treating ophthalmologists. Written narratives and sociodemographic and quality of life (QoL)-related data were anonymously collected through the project's webpage. Narratives were analysed through MAXQDA (VERBI Software, Berlin, Germany), NM classifications and content analysis.

RESULTS

A total of 171 patients with DED, 37 informal caregivers and 81 ophthalmologists participated in the research. DED was defined as a disabling condition by 19% of patients and 35% of caregivers; 70% of patients reported that a therapeutic alliance is an integral part of DED treatment and 32% hope for more effective therapies. Forty-four per cent of patients assessed their own QoL as good; however, DED emerged as importantly impacting work performance and social events. DED physical, emotional and economic burden and the cruciality of a trusting care relationship represent the main themes that emerged across all narratives, while empathy and effective treatment are among the factors favouring coping with DED.

CONCLUSION

This project marked a pioneering initiative investigating the lived experience of patients with DED through NM, simultaneously involving all viewpoints involved in the care pathway. NM enabled the unveiling of factors favouring the ability to cope with DED and its associated QoL implications and provided valuable insights to improve the therapeutic alliance.

Transcultural Validation of the Five-Item Dry Eye Questionnaire for Indonesian Populations

Purpose Indonesian dry eye (DE) disease (DED) prevalence data remain scarce, and Indonesian validations of the five-item Dry Eye Questionnaire (DEQ-5) are unavailable. We aimed to translate and validate an Indonesian language adaptation of the DEQ-5 (INDO-DEQ-5) for local populations. Methods Our observational study involved linguistic validation of the translation, reliability testing, dataset screening, and data collection through ophthalmic examinations and interviews. Outpatient adults with dry eye symptoms and formal DED diagnoses were included. Data were captured at patients' enrolment, at their self-administered INDO-DEQ-5, and at ophthalmic examinations. This data was statistically analyzed for agreement, test-retest reliability, and by a receiver operator characteristic (ROC) curve for dry eye sensitivity and specificity. Results Tear breakup time (TBUT) was the most frequently used clinical diagnostic parameter, with 96.8% of DED patients having abnormal TBUT. We captured 87.23% of all true DE cases, while the ROC and area under the ROC curve analyses found similar sensitivity between the INDO-DEQ-5 and the composite clinical diagnosis of DE, and TBUT was equivalent to the INDO-DEQ-5 in clinical diagnoses. The level of reliability of the INDO-DEQ-5 was moderate, and subscales were moderate or substantial. Conclusion The prediction of DE with TBUT was similar to predictions using the composite definition of clinical DE diagnosis, while the INDO-DEQ-5 diagnostic accuracy was similar to that of TBUT or a composite clinical diagnosis. Thus, the INDO-DEQ-5 is a reliable tool for the clinical evaluation and diagnosis of DE in Indonesian populations and will enable clinicians to rapidly collect accurate data to improve therapeutic management.

Dry Eye Para-Inflammation Management: Preclinical and Clinical Evidence on a Novel 0.2% Hyaluronic Acid-Based Tear Substitute with 0.001% Hydrocortisone Sodium Phosphate

Purpose: An innovative eyedrop formulation based on a combination of 0.2% hyaluronic acid and 0.001% hydrocortisone sodium phosphate (Idroflog®, Alfa Intes, Italy; HAC eyedrops) was granted a European Patent in 2016 and has been available on the market since 2019 in Europe and in other countries around the world. HAC eyedrops aim to synergize the moisturizing effects of hyaluronic acid with the mild anti-inflammatory properties of low-dose hydrocortisone, offering a more effective and safer alternative for treating dry eye disease (DED), targeting both tear film instability and dysfunctional para-inflammation. The activity of HAC eyedrops has been explored in different post-marketing clinical trials, in addition to preclinical studies. In this narrative review, we explored the available evidence on the use of HAC eyedrops for the management of para-inflammation in DED patients to provide a comprehensive overview of efficacy and safety data related to the use of this medical device in routine clinical practice. Methods: A literature search for preclinical and clinical data involving treatment with HAC eyedrops was conducted using PubMed/MEDLINE, considering only original research articles published in English, without time restrictions. Results: One preclinical and four clinical papers were retrieved. Preclinical evidence suggests that 0.001% hydrocortisone is able to control the expression of inflammatory markers, and this, together with the hydrating and lubricating properties of hyaluronic acid, leads to improvements in DED clinical signs, such as tear volume and the stability of the tear film. The results of clinical trials demonstrate that HAC eyedrops are able to improve the signs and symptoms of DED and that 0.001% low-dosage hydrocortisone can be helpful in preventing the progression to chronic stages of DED. Conclusions: HAC eyedrops represent a promising therapeutic strategy for the management of dysfunctional para-inflammation and offer a valuable addition to the armamentarium of treatments for DED.

Investigation of traditional Chinese medicine constitution in individuals afflicted by dry eye disease: A retrospective study

The aim of this study is to explore the traditional Chinese medicine (TCM) constitution among individuals suffering from dry eye disease. Following the diagnostic criteria outlined in TFO DEWS II, a total of 114 patients with dry eye were included in this study. Based on the classification criteria for dry eye, the patients were categorized into 3 distinct dry eye subtypes. Each participant underwent a thorough clinical assessment for dry eye, and their TCM pattern manifestations were assessed using the "Traditional Chinese Medicine Questionnaire for Dry Eye." The Nine Constitutions Assessment Method was utilized for TCM pattern differentiation and classification. Spearman's correlation analysis was employed to investigate the associations between TCM constitution and dry eye subtypes, clinical indicators, and the relationships between TCM syndromes and dry eye subtypes. Among the 114 patients, the Qi-Stagnation constitution was the most common, with variations in constitution distribution among different dry eye subtypes. Significant correlations were observed between the Blood-Stasis, Yin-Deficiency, Qi-Deficiency, and Yang-Deficiency constitutions and 2, 4, 1, and 4 dry eye indicators, respectively. Spearman's analysis revealed that 5 out of 50 TCM syndromes were associated with mixed dry eye, 5 with evaporative dry eye, and 3 with aqueous tear deficiency dry eye. Further analysis, using lasso regression and binary unconditional logistic regression identified dizziness, lumbago, and weakness as influencing factors for both mixed-type and evaporative-type dry eye. In this study, we extensively examined the TCM constitution in individuals with dry eye, offering valuable insights and guiding future TCM-related research in the context of dry eye. Additionally, we established correlations between TCM syndrome patterns and dry eye indicators.

Unveiling senescence-associated ocular pathogenesis via lacrimal gland organoid magnetic bioassembly platform and HMGB1-Box A gene therapy

Dry eye disease (DED) is a multifactorial aging disorder leading to tear film insufficiency and instability. Yet, an important knowledge gap lingers in understanding senescence-associated ocular pathogenesis, due to limited in vitro translational lacrimal gland (LG) models. Consequently, this remains a major roadblock to discover effective therapies for the restoration of tear film secretion. Herein, the authors reported the magnetic bioassembly of two LG organoid platforms to recapitulate functional and aging states. Using a proof-of-concept approach, porcine primary LG cells were assembled into organoids via a magnetic 3D bioprinting (M3DB) platform. This platform could form reproducible LG organoids with epithelial hallmarks (AQP5+) and exhibit epithelial secretory functions (lysozyme activity). DNA damage-induced senescence and cell death was induced with etoposide, and LG organoid hypofunction and senescence-associated pathogenesis were observed. To confer DNA protection against aging, a novel gene therapy with Box A domain of high-mobility group box-1 (HMGB1-Box A) previously established by our group, was applied here to prevent LG cellular senescence for the first time. HMGB1-Box A transfection prevented LG organoids from senescence-associated pathogenesis at the transcriptomic, metabolomic and proteomic levels. Thus, M3DB platforms could generate functional and DNA damage-induced senescence LG organoids, and this latter damage could be prevented with HMGB1-Box A gene therapy.

Effectiveness and safety of Jiejing Runmu decoction in treatment of dry eye disease

OBJECTIVE

To investigate the effectiveness and safety of Jiejing Runmu decoction in relieving the clinical manifestations of dry eye disease (DED).

DESIGN AND INTERVENTIONS

This single-arm prospective intervention study was conducted at the Peking University Third Hospital and People's Hospital of Yongqing. Of the 211 patients recruited, 200 completing the follow-up were included in the analysis. Patients received Jiejing Runmu decoction once a day for 4 weeks continuously, without any change in eye care habits. Individuals were evaluated at four time points: pretreatment (baseline), 2 weeks, 1 month, and 3 months (2 months after completion of treatment), using the Ocular Surface Disease Index (OSDI), tear film breakup time (TBUT), corneal fluorescein staining, Schirmer test I and meibomian gland assessments. Adverse effects were evaluated at each follow-up visit and systematic examinations were performed during the first and last visits.

RESULTS

OSDI, TBUT, corneal fluorescein staining, Schirmer test I, meibomian gland expressibility, and quality of secretions improved at 2 weeks, 1 month and 3 months compared to baseline (P < 0.0001). No significant differences were found between the sexes. Patients above 45 years showed worse subjective symptoms and objective signs, and greater improvements in corneal fluorescein staining, meibomian gland expressibility, and quality of secretions were observed in this group. No obvious adverse effects were detected during any follow-up visit.

CONCLUSION

Jiejing Runmu decoction significantly improved both the subjective symptoms and objective signs of DED, with favorable tolerance.

Influence of Environmental Factors with Clinical Signs and Symptoms in the Management of Dry Eye Disease

Background

This research aims to investigate the influence of environmental factors on the treatment efficacy of ocular lubricants in patients from urban areas with dry eye disease (DED).

Methods

A phase IV clinical trial, which included 173 patients from major cities in Mexico, was randomly assigned to use ocular lubricants four times a day for 30 days. Ocular Surface Disease Index (OSDI), noninvasive tear film break-up time (NIBUT), ocular staining, and conjunctival hyperemia (CH) among other factors like weather, and air pollution as covariates were analysed.

Results

After 30 days, OSDI score decreased by 14.8 points (p<0.001), and NIBUT increased by 2.9 seconds (p< 0.001), with longer values observed in patients recruited in autumn and winter (additional 1.8 seconds, p< 0.05) compared to those recruited in spring. Patients living in cities with cooler weather and high humidity, but low air quality had higher OSDI and conjunctival stain scores of up to 4.4 and 0.3 points, respectively, as compared to those living in cities with similar pollution and humidity levels but with higher temperatures (p-values= 0.019 and 0.050). Patients with moderate CH had an increase of up to 0.8 points in their corneal stain score (p< 0.010). We also found that ozone levels were related to the predicted changes in OSDI and NIBUT.

Conclusion

This study demonstrated the impact of environmental factors on the signs and symptoms of DED and suggests that patients residing in cities with inadequately controlled air pollution can benefit from using ocular lubricants to alleviate their symptoms.

Trial Registration

Trial is registered at clinicaltrials.gov (NCT04702776).

Advantages of Lissamine Green Vital Staining as an Endpoint in Dry Eye Clinical Trials

Purpose

The absence of a standardized diagnostic method for clinical signs of Dry Eye Disease (DED) complicates clinical trials for future treatments. This paper evaluated Lissamine Green (LG) conjunctival staining as a valid, stable and modifiable endpoint for both clinical practice and clinical trials.

Methods

Screening and pre-randomization data from two identically designed clinical trials for DED resulted in a pooled dataset of 494 subjects. Inclusion was based on reported symptoms, lissamine green (LG) conjunctival staining, Fluorescein (Fl) corneal and conjunctival staining, and Schirmer's Test (ST). Outcome measures were assessed based on the modifiability of LG staining to exposure to a Controlled Adverse Environment (CAE®), correlation of LG to Fl staining, relative variation of LG staining scores and Schirmer test scores, and the correlation of LG staining with symptom scores.

Results

The modifiability of LG conjunctival staining to environmental exposure was demonstrated, with nasal LG and FL staining displaying the most similar percent change. Nasal LG conjunctival staining scores for subjects with ST scores of less than 8mm were significantly higher than for subjects with ST greater than 8mm. LG staining scores were more consistent (25% change from baseline threshold) than ST scores. Finally, statistically significant correlations were found between LG staining and a number of symptom scores.

Conclusion

This evaluation demonstrates the superiority of the utilization of a clinical endpoint focused on ocular surface damage. The reproducibility and modifiability of LG conjunctival staining to controlled adverse environment, coupled with its significant correlation with symptoms, positions it as an exemplary clinical sign endpoint for clinical management and in clinical trials. Our findings advocate for the adoption of LG conjunctival staining as a primary endpoint in both clinical research and drug development, offering a more effective means of identifying and addressing ocular surface damage in the realm of DED.

Vectored Thermal Pulsation as a Treatment for Meibomian Gland Dysfunction: A Review Spanning 15 Years

The LipiFlow Thermal Pulsation System received its first marketing clearance for the treatment of meibomian gland dysfunction (MGD) 13 years ago. Since then, the evidence evaluating the effectiveness and safety of LipiFlow as a treatment for MGD has grown significantly. The objective of this comprehensive review was to summarize all clinical reports evaluating the effectiveness and safety of LipiFlow over the past 15 years. The literature was systematically reviewed, and 55 unique articles had subjective (patient-reported outcomes) and objective (meibomian gland function, tear production, and ocular staining) outcomes for extraction. Data were collected from 2101 patients and 3521 eyes treated with LipiFlow. Of these, effectiveness was evaluated in 2041 patients and 3401 eyes, and safety was evaluated in 1448 patients and 2443 eyes. Taken together, the studies demonstrate that a single 12-min treatment with LipiFlow safely improves signs and symptoms of MGD and associated evaporative dry eye disease (DED), and the benefits persist up to 3 years in some cases. The findings are corroborated by multiple meta-analyses and consensus guidelines. While some studies showed that daily eyelid hygiene, warm compress, and/or massage had a similar benefit to a single LipiFlow, these treatments were limited by inconvenience, discomfort, and non-compliance. The majority of studies evaluating safety reported no discomfort or pain associated with LipiFlow treatment, which supports the patient acceptability of LipiFlow therapy. All adverse events (AEs) related to LipiFlow were transient, non-vision-threatening, and did not require treatment. No studies reported serious AEs. The data obtained from 55 studies conducted globally overwhelmingly show that LipiFlow is effective and safe for the treatment of MGD and associated evaporative DED. The conclusions are supported by the diversity of the patient populations (geography, race, disease severity, and diagnosis), the large population treated with LipiFlow, the meta-analyses, and that this review analyzed all published clinical studies to date.

Effectiveness of 0.3% Hyaluronic Acid Eye Drops for Benign Essential Blepharospasm and Hemifacial Spasm with Botulinum Toxin-induced Dry Eye

Background

This study evaluates the effectiveness of 0.3% hyaluronic acid (HA) eye drops in patients receiving concurrent botulinum toxin (BoNT) injections for benign essential blepharospasm (BEB) or hemifacial spasm (HFS).

Methods

This randomized controlled cross-over trial study involved 14 patients with BEB and 33 patients with HFS randomized into two groups (early treatment and deferred treatment) for 3 months of treatment with 0.3% HA eye drops. Data collected at baseline, 3 months, and 6 months included Blepharospasm Severity Scale (BSS) score in patients with BEB; Samsung Medical Class Grading Scale score in patients with HFS; and dry eye symptoms, lower eyelid tear meniscus height (TMH), tear breakup time (TBUT), and corneal fluorescein staining in both groups.

Results

After 3 months of 0.3% HA instillation, patients with BEB in both groups showed significant improvement in BSS, TMH, TBUT, and the amelioration of subjective dry eye symptoms and corneal staining (P < 0.05). However, discontinuation of 0.3% HA eye drops worsened BSS, TMH, and TBUT. Patients with HFS also experienced significant improvement in Samsung Medical Class score, subjective dry eye symptoms, and objective corneal findings (P < 0.05).

Conclusions

Treatment with 0.3% HA eye drops led to significant improvement in spasm severity, and dry eye parameters, after 3 months of instillation in patients with BEB or HFS during concurrent treatment with BoNT injections. The 0.3% HA eye drops were safe and might serve as an add-on treatment for symptom improvement.

Measurement of lacrimal gland tissue stiffness for the diagnosis of visual display terminal-associated dry eye disease using shear wave elastography

Objective

This study aimed to evaluate whether lacrimal gland tissue stiffness can aid in diagnosing dry eye disease (DED) using shear wave elastography (SWE). We also aimed to assess the correlation between the subjective symptoms of ocular strain, SWE values, and other ocular examination findings (Schirmer's test and tear film breakup time [TBUT]) contributing to the diagnosis of DED.

Methods

This cross-sectional study recruited 300 participants who were engaged in video display terminal (VDT) work and had been diagnosed with DED by an ophthalmologist for more than one year, and 100 healthy participants without DED symptoms, from August 2020 to December 2021. The modified TFOS DEWS II was used for diagnosing DED. The ocular symptoms, Schirmer's test results, and TBUT of the participants were assessed using standardized methods. Eighty patients with DED and 40 sex- and age-matched healthy participants were selected as the observation and control group, respectively. The lacrimal gland tissue architecture was assessed using ultrasound.

Result

The SWE Emean value reflecting the lacrimal gland tissue stiffness of patients with DED was significantly higher than that of healthy participants (11.06 ± 1.26 for the DED group vs. 7.54 ± 1.27 for the control group, P < 0.001). In patients with DED, the Emean values of the lacrimal glands significantly correlated with the scores for subjective symptoms of ocular dryness (P < 0.001). No significant correlation was observed between the TBUT and Schirmer's test results. The area under the receiver operating characteristic (ROC) curve for SWE was 0.995. According to the ROC analysis results using an Emean cutoff value of 9.32 kPa for the diagnosis of DED, the sensitivity, specificity, positive predictive value（PPV）, and negative predictive （NPV）value were 97.5 %, 95 %, 100 %, and 95 %, respectively. Thus, SWE can be considered for diagnosing VDT-associated DED.

Conclusion

VDT-associated DED was associated with increased tear gland tissue stiffness. SWE aids in the quantitative detection of lacrimal gland tissue stiffness. Moreover, SWE significantly correlated with the subjective symptoms of DED.

Describing the Eye Health of Newly Arrived Refugees in Adelaide, South Australia

This study describes the eye health of newly arrived refugees attending a state-funded health service in Adelaide, South Australia, helping to address the paucity of data on the eye health of refugees. Patients attending the Refugee Health Service undergo comprehensive assessment by an on-site optometrist with accredited interpreters if they have eye symptoms, personal or family history of eye disease, or visual impairment (using World Health Organization definitions). A retrospective audit of this service was performed to obtain patient demographics, presenting best-corrected distance visual acuity (better-seeing eye), diagnoses, and management. In 2017-2018, 494 of the 1400 refugees attending the service underwent an optometry assessment (age range 1-86 years, mean age 33.1 ± 18.6 years, 53% female). Regions of origin included the Middle East (25%), Bhutan (24%), Afghanistan (22%), Myanmar (15%), and Africa (14%). Of the 124 cases of visual impairment, 78% resolved with corrective lenses and 11% were due to cataracts. Ophthalmology follow-up was required for 56 (11%) patients, mostly for cataracts (22 patients). Newly arrived refugees have high rates of visual impairment from refractive error and cataracts. Integration of optometry and state-based refugee health services may improve the timely detection and treatment of these conditions.

Dry eye in mind: Exploring the relationship between sleep and ocular surface diseases

PURPOSE

Dry Eye Disease (DED) is regarded as the most common ocular surface disease worldwide, entailing symptoms that have a major impact on the physical and psychological well-being of DED patients. In this context, the impact of sleep quality on DED has recently attracted attention. Indeed, although little is known about the mechanisms underlying the relationship between sleep and ocular surface diseases, recent evidence suggests that a reciprocal relationship exists between sleep quality and DED. Aim of the study was to investigate such relationship by means of both survey-based and instrumental analysis in a large population.

PATIENTS AND METHODS

The present cross-sectional study included 1182 DED patients who completed the Insomnia Severity Index (ISI) and the Ocular Surface Disease Index (OSDI) questionnaires. Moreover, tear break-up time (TBUT) and ocular surface staining (OSS) data of included patients were collected by physicians.

RESULTS

According to the findings of this study, in DED patients, the severity of dry eye symptoms and signs, assessed by OSDI score, TBUT, and ocular surface staining, is associated with more severe insomnia symptoms. Furthermore, higher severity of DED symptoms seems to be associated with the occurrence of nocturnal awakenings rather than with problems in falling asleep.

CONCLUSIONS

Present work contributes to the understanding of the complex relationship between DED and insomnia by showing that in a large population of DED patients, the more severe the insomnia, the more severe the DED symptoms and signs.

Quantitative Analysis of Tear Film in Patients on Atypical Antipsychotics

PURPOSE

To evaluate and compare the prevalence and severity of dry eye disease (DED) among patients on atypical antipsychotics with controls.

METHODS

This cross-sectional study was conducted on patients who were on atypical antipsychotic therapy (study group) and matched controls (control group). Prevalence of DED was assessed using tear break up time. Statistical analysis was done using SPSS. Chi-square test and t-test were used. p < 0.05 was taken as the level of statistical significance.

RESULTS

Prevalence of DED was significantly more in study group. Polytherapy group has significantly high DED compared with monotherapy. Among monotherapy, clozapine had highest prevalence of DED (p-0.013) and among the polytherapy, clozapine-quetiapine had highest prevalence of dry eye.

CONCLUSION

Prevalence of DED was higher among antipsychotics than the normal population, and in polytherapy than monotherapy group. The patients on clozapine (monotherapy) and clozapine with quetiapine (polytherapy) had highest prevalence of DED.

Assessment of leukocyte and systemic inflammation index ratios in dyslipidemia patients with dry eye disease: a retrospective case‒control study

BACKGROUND

Dry eye disease (DED) is a complication of dyslipidemia (DLP) that is caused by metabolic syndrome and increased inflammation. This research aimed to assess leukocyte and systemic inflammation index ratios as potential biomarkers for systemic inflammation in dyslipidemia patients with dry eye disease (DLP-DED).

METHODS

Several blood biomarkers were studied in 32 patients with DLP-DED (study group) and 63 patients with DLP-only (control group). The evaluated blood biomarkers included specific systemic inflammation index ratios, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), and neutrophil-to-lymphocyte and platelet ratio (NLPR), and lipid profiles, such as total cholesterol (TC), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), triglyceride (TG), albumin (ALB), and C-reactive protein (CRP) levels.

RESULTS

Lymphocyte levels were significantly greater in the DLP-DED group than in the DLP-only group (P = 0.044). In addition, a significant negative correlation between HDL and the NLPR (P = 0.007; r= -0.428) and a significant negative correlation between the serum ALB concentration and the PLR (P = 0.008; r= -0.420) were identified as potential inflammatory predictors of DLP-DED.

CONCLUSION

The findings of this study suggest that patients with DLP-DED may benefit from routine blood monitoring of their elevated lipid profile and blood inflammatory biomarkers, such as CRP, leukocytes, and systemic inflammation index ratios (NLR, PLR, MLR, and NLPR), to reduce the complications of DLP on ocular health. The correlation data suggest that the NLPR, PLR, serum ALB concentration, and serum HDL concentration may be valuable inflammatory biomarkers in DLP-DED patients. More research is required to ascertain the significance of the NLR, PLR, MLR, and NLPR and the additive role that leukocytes play.

Effect of low dose honey on the apoptosis and inflammation gene expression in corneal limbal stem cells and keratocytes and its efficacy as an ophthalmic formulation in the treatment of dry eye: in-vitro and clinical study

Background

The use of honey as an eye treatment encounters challenges due to its high osmolarity, low pH, and difficulties in sterilization. This study addresses these issues by employing a low concentration of honey, focusing on both in-vitro experiments and clinical trials for treating dry eye disease in corneal cells.

Methods

In the in-vitro experiment, we investigated the impact of a 1% honey-supplemented medium (HSM) on limbal stem cells (LSCs) and keratocytes using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay and real-time polymerase chain reaction (PCR) for BCL-2, BAX, and IL-1β gene expression. Simultaneously, in the clinical trial, 80 participants were divided into two groups, receiving either a 1% w/v honey ophthalmic formulation or a placebo for 3 months. Study outcomes included subjective improvement in dry eye symptoms, tear break-up time (TBUT), and Schirmer's test results.

Results

MTT results indicated that 1% HSM did not compromise the survival of corneal cells and significantly reduced the expression of the IL-1β gene. Additionally, participants in the honey group demonstrated a higher rate of improvement in dry eye symptoms and a significant enhancement in TBUT values at the three-month follow-up. However, there was no significant difference between the study groups in terms of Schirmer's test values. No adverse events were observed or reported.

Conclusion

In conclusion, 1% honey exhibits anti-inflammatory and anti-infective properties, proving effective in ameliorating dry eye symptoms and enhancing tear film stability in patients with dry eye disease.Clinical Trial Registration: https://irct.behdasht.gov.ir/trial/63800.

Bilateral Sutureless Application of Human Dehydrated Amniotic Membrane with a Specialised Bandage Contact Lens for Moderate-to-Severe Dry Eye Disease: A Prospective Study with 1-Month Follow-Up

Purpose

To assess changes in symptoms and ocular surface signs following a bilateral sutureless treatment of dehydrated amniotic membrane (dAM) under a specialised bandage contact lens (sBCL) in patients with moderate-to-severe dry eye disease (DED).

Patients and Methods

In this prospective pre-post interventional study, 35 patients diagnosed with moderate-to-severe DED, with an Ocular Surface Disease Index (OSDI) score >30 on current treatment, were enrolled. Assessments were conducted at baseline (day -30), after 30 days run-in with no additional treatment (day 0 - control), and 30 days post sBCL+dAM treatment (day 30 - treatment). Intervention involved two successive bilateral 4-5 day sutureless applications of dAM (17mm diameter, with a 6 mm central aperture, Omnigen® VIEW) under an 18mm sBCL (OmniLenz®). Symptomatology and ocular signs were measured using OSDI, Dry Eye Questionnaire-5 (DEQ-5), Symptom Assessment iN Dry Eye (SANDE), and other ocular surface health indicators including non-invasive breakup time, corneal and conjunctival staining, and lid wiper epitheliopathy length and width (LWE).

Results

While symptomatology remained stable during the 30-day no-treatment run-in, 1-month post-dAM treatment, there was a significant reduction in OSDI scores (from 55.8 to 32.3, p<0.001), DEQ-5 (from 14.6 to 10.0, p<0.001), SANDE frequency (from 65.2 to 43.6, p<0.001), and SANDE severity (from 59.8 to 41.1, p<0.001). Additionally, there was a notable decrease in the width of LWE staining, from grade 2 (50-75% of the lid wiper) to grade 1 (25-50% of the lid wiper) (p=0.011).

Conclusion

A bilateral 8-10-day treatment duration with dAM applied with sBCL demonstrated a 31 to 42% improvement in symptomatology and a decrease in ocular surface signs of mechanical stress. This innovative bilateral treatment approach offers a promising treatment modality for patients with refractory moderate-to-severe DED.

The Long-Term Effect on Dry Eye of Posterior Approach Ptosis Surgery Vs. Upper Eyelid Blepharoplasty

PURPOSE

To examine the long-term effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome.

METHODS

This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining.

RESULTS

The participants included 25 post-MMCR patients with a mean follow-up of 4.94 ± 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 ± 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p < .01 and p < .01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p = .044). Those parameters were not significant in the blepharoplasty group.

CONCLUSIONS

Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye.

Validation of an Ion-Pair Reverse Phase High-Performance Liquid Chromatography Method for the Detection of Major Components and Related Substances in Diquafosol Sodium Eye Drops

A simple, feasible, isocratic elution, and stable reversed-phase high performance liquid chromatography method was established and verified. The chromatographic conditions are as follows: EF-C18H, 4.6 × 250 mm, 5 μm column; column temperature 30 °C; for the mobile phase 27.2 g of KH2PO4 and 8.5 g of tetrabutylammonium hydrogen sulfate were taken, 2500 mL of water was added to dissolve, and the pH was adjusted to 6.7 with phosphoric acid:methanol solution with a ratio of 84:16 (V:V). The flow rate was 1.0 mL/min; the injection volume was 10 μL; and the wavelength was 262 nm. According to the current ICH guidelines, the developed method was verified, and the system suitability, specificity, LOD, LOQ, linearity, range, accuracy, repeatability, durability, and solution stability of the proposed method were verified. The validation results demonstrated that the LOQ for the method was 0.05% and the LOD was 0.02%. The content was detected within the concentration range of 300 to 900 μg/mL. The relationship between concentration and measurement was linear, with an r2 of >0.999. The concentration of impurities ranged from 0.3 to 4.5 μg/mL. A good linear correlation was observed within the range of g/mL, with a coefficient of determination r2 greater than 0.999. The accuracy and repeatability met the specified criteria.

Exposure limits for indoor volatile substances concerning the general population: The role of population-based differences in sensory irritation of the eyes and airways for assessment factors

Assessment factors (AFs) are essential in the derivation of occupational exposure limits (OELs) and indoor air quality guidelines. The factors shall accommodate differences in sensitivity between subgroups, i.e., workers, healthy and sick people, and occupational exposure versus life-long exposure for the general population. Derivation of AFs itself is based on empirical knowledge from human and animal exposure studies with immanent uncertainty in the empirical evidence due to knowledge gaps and experimental reliability. Sensory irritation in the eyes and airways constitute about 30-40% of OELs and is an abundant symptom in non-industrial buildings characterizing the indoor air quality and general health. Intraspecies differences between subgroups of the general population should be quantified for the proposal of more 'empirical' based AFs. In this review, we focus on sensitivity differences in sensory irritation about gender, age, health status, and vulnerability in people, based solely on human exposure studies. Females are more sensitive to sensory irritation than males for few volatile substances. Older people appear less sensitive than younger ones. However, impaired defense mechanisms may increase vulnerability in the long term. Empirical evidence of sensory irritation in children is rare and limited to children down to the age of six years. Studies of the nervous system in children compared to adults suggest a higher sensitivity in children; however, some defense mechanisms are more efficient in children than in adults. Usually, exposure studies are performed with healthy subjects. Exposure studies with sick people are not representative due to the deselection of subjects with moderate or severe eye or airway diseases, which likely underestimates the sensitivity of the group of people with diseases. Psychological characterization like personality factors shows that concentrations of volatile substances far below their sensory irritation thresholds may influence the sensitivity, in part biased by odor perception. Thus, the protection of people with extreme personality traits is not feasible by an AF and other mitigation strategies are required. The available empirical evidence comprising age, lifestyle, and health supports an AF of not greater than up to 2 for sensory irritation. Further, general AFs are discouraged for derivation, rather substance-specific derivation of AFs is recommended based on the risk assessment of empirical data, deposition in the airways depending on the substance's water solubility and compensating for knowledge and experimental gaps. Modeling of sensory irritation would be a better 'empirical' starting point for derivation of AFs for children, older, and sick people, as human exposure studies are not possible (due to ethical reasons) or not generalizable (due to self-selection). Dedicated AFs may be derived for environments where dry air, high room temperature, and visually demanding tasks aggravate the eyes or airways than for places in which the workload is balanced, while indoor playgrounds might need other AFs due to physical workload and affected groups of the general population.

The Effect of Ptosis Surgery on Meibomian Glands and Dry Eye Syndrome

PURPOSE

To investigate the effect of ptosis surgery on dry eye disease as measured by dry eye parameters and meibomian gland function.

METHODS

This prospective, case series study included patients with involutional ptosis with no prior history of dry eye disease who were scheduled for a levator aponeurosis advancement procedure. Dry eye evaluation included the ocular surface disease index (OSDI) questionnaire as well as objective measurements, which included meibomian gland loss measured by meibography, meibomian gland disease grading, tear breakup time (TBUT), corneal and conjunctival fluorescein staining, tear meniscus height, and Schirmer testing. All dry eye measurements were recorded preoperatively and repeated 21-28 days postoperatively.

RESULTS

A total of 30 eyes were included with a mean age of 65.6 ± 11.9 years. There was a significant improvement in margin reflex distance1 (MRD1) postoperatively ( p < 0.001) and a significant decrease in upper lid margin thickening ( p = 0.022). There were no significant differences between the pre- and postoperative measurements in meibomian gland loss, TBUT, corneal and conjunctival fluorescein staining, tear meniscus height, and the Schirmer test. OSDI was increased nonsignificantly postoperatively (16.094 vs. 24.296, respectively, p = 0.107).

CONCLUSION

The levator aponeurosis advancement procedure does not affect the eyelid meibomian glands, nor does it cause an increase in dry eye signs and symptoms, according to the measured parameters.

The Efficacy and Safety of Chinese Eye Exercise of Acupoints in Dry Eye Patients: A Randomized Controlled Trial

INTRODUCTION

Dry eye disorder (DED) is a growing global issue linked to excessive digital screen time. Chinese eye exercise of acupoint (CEA), a set of self-massages on shared Chinese acupuncture (CA), has been used to reduce visual-related ocular symptoms and possibly as an alternative treatment for DED. This study aimed to assess the efficacy and safety of CEA.

METHODS

A single-blind randomized controlled trial was conducted at Thammasat University Hospital in Thailand, recruiting 56 participants aged 20-60 years, equally divided into two groups: the treatment group with CEA and the control group with standard lid hygiene treatment (STD). The intervention program lasted 12 weeks.

MAIN OUTCOME MEASURES

Ocular Surface Disease Index (OSDI), tear break-up time (TBUT), Schirmer-I test (SIT), corneal surface staining (CSS), and self-recorded forms for safety and adverse effects were measured at baseline, week 4, and week 12. An independent sample t test, paired t test, and repeated measures (ANOVA) were used to compare results between both groups, study visits, and primary and secondary outcome measurements, respectively. The p values <0.05 were considered statistically significant.

RESULTS

The characteristics were not statistically different between both groups at the baseline. The mean OSDI scores were significantly reduced in both groups at week 4 and week 12 compared to baseline (p value <0.05). Additionally, both CEA and STD showed significant improvement in TBUT and SIT (p value <0.05). CSS was significantly improved only in the CEA groups (p value <0.05). No significant differences were observed between the study groups, except for SIT at week 12 (p value <0.05). For the safety, there were no adverse side effects in either group.

CONCLUSION

CEA seemed to be as effective as STD in improving the OSDI, TBUT, and SIT of DED without causing any side effects.

Einleitung

Das Trockene Auge (Dry eye disorder, DED) ist weltweit ein zunehmendes Problem, das mit übermässiger Bildschirmarbeit zusammenhängt. Die chinesische Augenübung der Akupunkturpunkte (Chinese eye exercise of acupoint, CEA), eine Reihe von Selbstmassagen an gemeinsamen CA-Akupunkturpunkten, wird zur Linderung visusbezogener Augensymptome und als mögliche alternative Behandlung für DED eingesetzt. Mit dieser Studie sollte die Wirksamkeit und Sicherheit von CEA bewertet werden.

Methoden

Am Thammasat-Universitätsklinikum in Thailand wurde eine einfach verblindete, randomisierte, kontrollierte Studie mit 56 Teilnehmern im Alter von 20 bis 60 Jahren durchgeführt, die zu gleichen Teilen zwei Gruppen zugewiesen wurden: die Behandlungsgruppe mit CEA und die Kontrollgruppe, die die Standard-Lidhygienebehandlung erhielt (STD). Das Interventionsprogramm dauerte 12 Wochen. Die Haupt-Zielkriterien, der Ocular Surface Disease Index (OSDI), die Tränenfilmaufreisszeit (tear break-up time, TBUT), der Schirmer-I-Test (SIT), das Corneal Surface Staining (CSS) und Selbstauskunftsformulare zur Sicherheit und zu unerwünschten Wirkungen wurden zu Beginn der Behandlung, in Woche 4 und in Woche 12 ermittelt. Für den Vergleich der Ergebnisse zwischen den beiden Gruppen, den Studienvisiten bzw. den primären und sekundären Zielkriterien wurden ein t Test für unabhängige Stichproben, ein t Test für paarige Stichproben und eine ANOVA mit Messwiederholungen verwendet. p-Werte <0,05 galten als statistisch signifikant.

Ergebnisse

Hinsichtlich der Merkmale bestand zwischen den beiden Gruppen kein statistischer Unterschied bei Studienbeginn. In beiden Gruppen fielen die mittleren OSDI-Scores in Woche 4 und Woche 12 im Vergleich zum Ausgangswert signifikant geringer aus (p-Wert <0,05). Darüber hinaus zeigten sowohl die CEA- als auch die STD-Gruppe eine signifikante Verbesserung der TBUT- und SIT-Werte (p-Wert <0,05). Das CSS verbesserte sich nur in der CEA-Gruppe signifikant (p-Wert <0,05). Zwischen den Studiengruppen waren keine signifikanten Unterschiede zu beobachten, ausser beim SIT in Woche 12 (p-Wert <0,05). Was die Sicherheit betrifft, so traten in beiden Gruppen keine unerwünschten Nebenwirkungen auf.

Schlussfolgerung

Die CEA schien die OSDI-, TBUT- und SIT-Werte bei DED ebenso wirksam zu verbessern wie die Standardbehandlung, ohne Nebenwirkungen zu verursachen.

Ocular surface parameter changes in the untreated fellow eye after unilateral cataract surgery with short-term administration of anti-inflammatory eye drops

This study aimed to investigate the changes in clinical parameters of dry eye disease and meibomian gland dysfunction in both the operated and untreated fellow eyes of patients who underwent unilateral cataract surgery with the short-term administration of anti-inflammatory eye drops in the surgical eye. The medical charts of 57 consecutive patients who underwent unilateral cataract surgery and received 1% prednisolone acetate and non-steroidal anti-inflammatory drug (NSAID, 0.1% bromfenac sodium) eye drops were reviewed. The preoperative ocular surface disease index questionnaire score (38.9 ± 20.5) decreased significantly to 15.2 ± 16.4 at post-surgical 1 week and further to 12.8 ± 11.4 after 1 month. Although meibum quality grade increased and corneal sensitivity decreased at 1 week in operated eyes, corneal erosion scores and Sjogren's International Collaborative Clinical Alliance ocular staining scores even improved over a month in the untreated fellow eyes. The tear matrix metalloproteinase (MMP)-9 grade decreased in both operated eyes and untreated fellow eyes after 1 month from surgery. In conclusion, the short-term topical anti-inflammatory treatment using steroid and NSAID eye drops in the operated eye after cataract surgery decreased subjective ocular surface discomfort and improved ocular surface staining scores and tear MMP-9 expression in the untreated fellow eyes.

Assessment of the prevalence and risk factors for dry eye symptoms among Romanian medical students using the ocular surface disease index - a cross-sectional study

BACKGROUND

This study aims to assess how Romanian medical students suffer from dry eye disease symptoms, establish the prevalence and severity of dry eye (DE) symptoms and identify potential risk factors.

METHODS

An analytical, cross-sectional study was conducted on students from "Carol Davila" University of Medicine, Romania, after the final examination period of July 2022. The OSDI score (Ocular Surface Disease Index©) was applied in an online survey. The study adopted the standards used by other authors, who defined symptomatic DED as an OSDI score greater than 12. The chi-square test was used to establish statistical significance at a cutoff value of p < 0.05. The predictive model was created using linear logistic regression analysis. The goodness of fit of the logistic regression model was assessed using the Hosmer-Lemeshow test. When the severity outcome had a nominal categorical form, multinomial regression analysis with normal subjects as a reference was performed. The distribution of the severe type of symptomatology across sex categories and years of study was analyzed using a nonparametric test (Independent-Samples Kruskal-Wallis Test).

RESULTS

A total of 274 answers were received from 81.4% females and 18.6% males with a response rate of 35.58%. The mean age was 22.7 years ± 1.66 with an age range between 20 and 25 years old. Using the OSDI score, we established that the overall prevalence of DE symptoms was 83.6% (95%CI: 79.6%, 88%), with an 85.2% (95%CI: 80.5%, 89.8%) prevalence in females and 76.5% (95%CI: 65%,88%) in males. The severe form of DE was the most prevalent, regardless of the study year or sex. Increased screen time (p-value < 0.05) and non-smokers (p-value < 0.05) were proven risk factors. The predictive model which includes the explanatory variables (sex, contact lens wearers, smoking, oral contraceptives, screen time) proved an 84.7% predictability for symptomatic DE and was able to better predict the dependent variable than the intercept model only (p-value < 0.05). Smoking (p = 0.002) and screen time (p = 0.009) preserved their significance in the multinominal regression as well.

CONCLUSIONS

This is the first study to report the epidemiology of DE symptoms among Romanian medical students. OSDI revealed a high prevalence of symptomatic DE in medical students. Screen time, although not the only factor, likely plays a role in exacerbating the disease. This information can be used to inform healthcare policies, establish occupational health guidelines, and implement preventive measures for individuals in similar high-stress academic or professional environments.

Effects of climate factors and Demodex infestation on meibomian gland dysfunction-associated dry eye diseases

We examined the effects of climatic factors and Demodex infestations on meibomian gland dysfunction (MGD)-associated dry eye disease (DED) in a cross-sectional study. This study included 123 patients from Tianjin and Chengdu regions, and climate factors and the Air Quality Index (AQI) were recorded for one year. Ocular surface parameters and Demodex infestations were evaluated using various tests. Significant differences in all climatic factors and AQI were observed between Tianjin and Chengdu (P < 0.01), and ocular surface parameters also differed significantly between the two regions (P < 0.05). Temperature, relative humidity, and precipitation positively correlated with tear break-up time (BUT), meibum gland expressibility, and lid margin irregularity but negatively correlated with lissamine green staining scores (P < 0.05). Wind speed and atmospheric pressure positively correlated with corneal fluorescein staining and lissamine green staining but negatively correlated with BUT and lid margin irregularity (P < 0.05). AQI positively correlated with DED symptoms and corneal findings but negatively correlated with tear film stability and meibomian gland characteristics (P < 0.05). Demodex infestation was only positively correlated with meibum quality scores (P < 0.05). Our findings suggest that geographic climates influence ocular surface characteristics in MGD-associated DED, with daily precipitation potentially playing a significant role, and Demodex infestation contributes to meibum gland degeneration.

Comparing the effect of benzalkonium chloride-preserved, polyquad-preserved, and preservative-free prostaglandin analogue eye drops on cultured human conjunctival goblet cells

PURPOSE

To investigate the effect of benzalkonium chloride (BAK)-preserved latanoprost and bimatoprost, polyquad (PQ)-preserved travoprost, and preservative-free (PF) latanoprost and tafluprost, all prostaglandin analogues (PGAs), on human conjunctival goblet cell (GC) survival. Furthermore, to investigate the effect of BAK-preserved and PF latanoprost on the cytokine secretion from GC.

METHODS

Primary human conjunctival GCs were cultivated from donor tissue. Lactate dehydrogenase (LDH) and tetrazolium dye colorimetric (MTT) assays were used for the assessment of GC survival. A cytometric bead array was employed for measuring secretion of interleukin (IL)-6 and IL-8 from GC.

RESULTS

BAK-preserved latanoprost and bimatoprost reduced cell survival by 28% (p = 0.0133) and 20% (p = 0.0208), respectively, in the LDH assay compared to a negative control. BAK-preserved latanoprost reduced cell proliferation by 54% (p = 0.003), BAK-preserved bimatoprost by 45% (p = 0.006), PQ-preserved travoprost by 16% (p = 0.0041), and PF latanoprost by 19% (p = 0.0001), in the MTT assay compared to a negative control. Only PF tafluprost did not affect the GCs in either assay. BAK-preserved latanoprost caused an increase in the secretion of pro-inflammatory IL-6 and IL-8 (p = 0.0001 and p = 0.0019, respectively) compared to a negative control, which PF latanoprost did not.

CONCLUSION

BAK-preserved PGA eye drops were more cytotoxic to GCs than PQ-preserved and PF PGA eye drops. BAK-preserved latanoprost induced an inflammatory response in GC. Treatment with PF and PQ-preserved PGA eye drops could mean better tolerability and adherence in glaucoma patients compared to treatment with BAK-preserved PGA eye drops.

Prevalence and Risk Factors of Dry Eye Disease in Association With the Increased Use of Electronic Devices Among University Students in Western Saudi Arabia

AIM

Dry eye disease (DED) is a prevalent ocular condition that significantly impacts individuals' quality of life and performance. It is charac-terized by the instability of the tear film, which causes ocular surface inflamma-tion and damage that leads to ocular symptoms. However, this study aimed to determine the prevalence of DED and identify associated risk factors among university students in western Saudi Arabia.

METHODS

A total of 402 university students participated in this study. The sample size was determined using Raosoft software (Raosoft, Inc., Seattle, WA), considering an estimated student population of 20,000. Data were collected between January and March 2023 through an online questionnaire distributed to the participants. The questionnaire comprised three sections, covering general information, behaviors related to digital device (DD) use, and the validated Arabic version of the Ocular Surface Disease Index (OSDI) questionnaire. OSDI scores were calculated, and the severity of DED was categorized using established cutoff points.

RESULTS

Among the 402 university students who took part in the survey, the majority (63.2%) were aged between 21 and 25 years, with females representing the dominant gender (72.9%). Notably, 90.8% of participants reported using DDs at bedtime. Over 60% of students had been using DDs for more than 10 years, and approximately 61.7% reported having more than six hours of daily screen time. Mobile devices were the most commonly used electronic devices (67.2%), and TikTok emerged as the most frequently used application (35.6%). Based on the OSDI criteria, 21.1% of students had mild DED symptoms, 14.9% had moderate symptoms, and 38.6% had severe symptoms. Hence, the prevalence of students exhibiting positive DED symptoms was 74.6%, while 25.4% were negative.

Conjunctival and nasal microflora in patients on topical cyclosporine for dry eye

Introduction: Dry eye is a common ocular condition causing discomfort and visual disturbances. Anti-inflammatory agents like Cyclosporine A (CsA) are often used in its treatment. However, the impact of CsA on ocular flora remains understudied. This research aimed to evaluate changes in conjunctival and nasal microflora in patients receiving topical cyclosporine for dry eye. Methods: In this cross-sectional study, conjunctival and nasal samples were collected from two groups of dry eye patients. Group 1 consisted of 38 patients using CsA eye drops, while Group 2 included 34 patients using preservative-free artificial tear drops. Bacterial cultures were grown from the samples, and the identified organisms underwent antibiotic susceptibility testing. Additionally, alpha diversity metrics were employed to assess the diversity of bacterial species in the samples. Results: Bacterial growth was observed in 75% of conjunctival samples and 97.22% of nasal samples. Staphylococcus epidermidis was the predominant organism in both groups. Alpha diversity analysis showed no significant differences in Shannon diversity and OTU richness between the groups for most bacterial species. Antibiotic susceptibility tests revealed no substantial variations in resistance patterns between the groups. Conclusion: This study provides valuable insights into the impact of CsA eye drops on conjunctival and nasal flora in dry eye patients. The findings suggest that CsA does not significantly influence the composition, diversity, or antibiotic resistance patterns of ocular flora. Long-term topical cyclosporine treatment for dry eye does not significantly impact conjunctival microflora or lead to antibiotic resistance. These results have important implications for the safe use of CsA in patients undergoing ocular treatments, particularly those at risk of intraocular infections.

Overview of CFTR activators and their recent studies for dry eye disease: a review

The cystic fibrosis transmembrane conductance regulator (CFTR) gets activated via the cAMP signaling pathway and is present in various secretory epithelial cells, including conjunctival and corneal epithelial cells. Activation of CFTR leads to fluid secretion in both mouse and human ocular surfaces. Dry eye disease is a significant health problem for which limited therapeutic options are available. In this review, on the one hand, small molecule CFTR activators with different chemical structures are summarized, and on the other hand, the pharmacological activity test and structural optimization of small molecule CFTR activators in the treatment of dry eye are outlined. The purpose of this review is to highlight the important role of CFTR activators in the treatment of dry eye disease and their potential as a new strategy for the treatment of dry eye disease.

The use of benzalkonium chloride in topical glaucoma treatment: An investigation of the efficacy and safety of benzalkonium chloride-preserved intraocular pressure-lowering eye drops and their effect on conjunctival goblet cells

ENGLISH SUMMARY

Glaucoma is a leading cause of the global prevalence of irreversible blindness. The pathogenesis of glaucoma is not entirely known, but the major risk factors include advancing age, genetic predisposition, and increased intraocular pressure (IOP). The only evidence-based treatment is a lowering of IOP through the use of eye drops, laser procedures, or surgical interventions. Although laser treatment is gaining recognition as a first-choice treatment option, the most common approach for managing glaucoma is IOP-lowering eye drops. A major challenge in the treatment is the occurrence of adverse events and poor adherence. In this context, the ocular surface is an area of great concern, as most glaucoma patients have dry eye disease (DED), which is largely caused by eye drops. Preservation with benzalkonium chloride (BAK) is a controversial topic due to its potential role as a significant cause of DED. A systematic review and meta-analyses investigate potential differences in efficacy and safety between BAK-preserved and BAK-free anti-glaucomatous eye drops (I). Many of the included studies report on ocular surface damage caused by the application of BAK-preserved eye drops. However, the meta-analyses addressing hyperemia, number of ocular adverse events, and tear break-up time did not identify any significant differences. The latter is likely due to varying measurement methods, different endpoints, and study durations. It is, therefore, possible that the large variations between the studies conceal differences in the safety profiles. The efficacy meta-analysis finds that there are no differences in the IOP-lowering effect between BAK-preserved and BAK-free eye drops, indicating that BAK is not necessary for the effectiveness of eye drops. To promote more homogeneous choices of endpoints and methods when evaluating BAK-preserved and BAK-free glaucoma treatments, a Delphi consensus statement was performed. In this study, glaucoma experts and ocular surface disease experts reached consensus on the key factors to consider when designing such studies (II). The hope is to have more studies with comparable endpoints that can systematically show the potentially adverse effects of BAK. The preclinical studies in the current Ph.D. research focus on conjunctival goblet cells (GCs). GCs are important for the ocular surface because they release the mucin MUC5AC, which is an essential component of the inner layer of the tear film. BAK preservation may damage the GCs and result in a low GC density, leading to an unstable tear film and DED. The most commonly used IOP-lowering drugs are prostaglandin analogs (PGAs). Thus, the conducted studies investigate the effect of PGAs preserved in different ways on GCs. BAK-preserved latanoprost is cytotoxic to primary cultured human conjunctival GCs and results in a scattered expression of MUC5AC, in contrast to negative controls, where MUC5AC is localized around the cell nucleus (III). Preservative-free (PF) latanoprost is not cytotoxic and does not affect the MUC5AC expression pattern. Furthermore, BAK-preserved travoprost is found to be cytotoxic in a time-dependent manner, while Polyquad®-preserved travoprost does not affect GC survival at any measured time point (IV). Both Polyquad and BAK induce scattered expression of MUC5AC. The cytotoxicity of BAK-preserved PGA eye drops is higher compared to the safer profile of PF and Polyquad-preserved PGA eye drops (V). Additionally, PF latanoprost does not increase the release of the inflammatory markers interleukin (IL)-6 and IL-8, unlike BAK-preserved latanoprost. A review highlights the active and inactive components of IOP-lowering eye drops (VI). Several preclinical and clinical studies have identified adverse effects of BAK. Although other components, such as the active drug and phosphates, can also cause adverse events, the review clearly states that BAK alone is a major source of decreased tolerability. The conclusion of this thesis is that BAK preservation is unnecessary and harmful to the ocular surface. The preclinical studies demonstrate that GCs die when exposed to BAK. Furthermore, they find that BAK induces a pro-inflammatory response. The review included in the thesis concludes that BAK should be phased out of eye drops for chronic use. Overall, the inclusion of BAK poses a risk of developing DED and poor adherence, which can ultimately lead to disease progression and blindness.