Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007)

Relationship between adolescent gaming addiction and myopia, ocular surface condition, and health status: a questionnaire based cohort study

This study explores the relationship between gaming addiction among Chinese adolescents and their myopia, ocular surface conditions, and overall health. A cross-sectional questionnaire-based cohort study included 835 participants aged 13-17, selected from 3300. Tools included the Hospital Anxiety and Depression Scale (HADS), Van Dream Anxiety Scale (VDAS), 36-Item Short-Form Health Survey (SF-36), Ocular Surface Disease Index (OSDI), Internet Addiction Test (IAT), and Internet Gaming Disorder Scale-20 (IGD-20). Linear regression, Pearson correlation, and unpaired t-tests were used. Gaming addiction correlated with worsened physical and mental health. Older age and longer gaming duration were linked to higher myopia rates. Males scored higher on HADS, VDAS, IAT, and IGD-20 but lower on SF-36 than females. Myopic gamers had longer gaming durations and higher IAT scores. IGD-20 scores for gamers playing 5-6+ hours daily showed stronger correlations with HADS, VDAS, and OSDI. Online gaming significantly impacts vision, physical and mental health, and ocular surface conditions. Score differences between groups underscore the need for interventions, including mental health support, cognitive-behavioral correction, and preventive eye care.

A comprehensive scoping review of methodological approaches and clinical applications of tear fluid biomarkers

Tear fluid is an emerging source of disease biomarkers, drawing attention due to its quick, inexpensive, and non-invasive collection. The advancements in detection techniques enable the measurement of ultra-low biomarker levels from small sample volumes typical of tear fluid. The lack of standardized protocols for collection, processing, and analysis of tear fluid remains a significant challenge. To address this, we convened the Tear Research Network Review Taskforce in 2022 to review protocols from the past three decades, providing a comprehensive overview of the methodologies used in tear fluid biomarker research. A total of 1484 articles published from January 1974 to May 2024 from two electronic databases, Embase and Ovid MEDLINE, were reviewed. An exponential increase in the number of articles on tear fluid biomarkers was observed from 2015 onwards. The two most commonly reported collection methods were; glass capillaries (45.2%), and Schirmer's strips (25%), with glass capillary tube collection remaining the most frequent method until 2019, when Schirmer's strips became the leading method. Most articles analyzed tear fluid proteins (65%) and focused on a single analyte (32.3%). In recent years, an increase was observed in the type and number of examined analytes. The differences in the reported methodologies and protocols underscore the need for standardization and harmonization within the field of tear fluid biomarkers to minimize methodological differences and reduce variability in clinical outcomes. Consistent and detailed reporting is essential for improving the reproducibility and validity of tear fluid studies, in order to advance their potential clinical applications.

Comparison of non-invasive and fluorescein tear film break-up time in a 65-year-old Norwegian population: a cross-sectional study

OBJECTIVES

Measurement of tear film stability is central in dry eye disease (DED) diagnosis. In this study, we aimed to compare the performance of two methods of tear film stability measurement: non-invasive tear break-up time (NIBUT) and fluorescein tear film break-up time (FTBUT).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

The study involved 132 subjects of 65-year-old inhabitants of the Oslo region who were not seeking ophthalmic care.

INTERVENTIONS

The participants underwent a battery of DED tests, including NIBUT measured on Oculus Keratograph 5M and a traditional method using fluorescein drops (FTBUT). Oculus Keratograph 5M measures two types of NIBUT:; appearance time of the first dry spot (NIBUTFirst) and average NIBUTAvg.

RESULTS

74 participants (56%) were female and 58 were male (44%). Subjects presented with varying degrees of DED signs and symptoms. Mean values of NIBUTFirst and FTBUT from all the participants were significantly different (6.2±4.9 s vs 8.6±6.2 s, p<0.0001). There was also a significant difference between NIBUTFirst and NIBUTAvg values (6.2±4.9 s vs 8.3±5.5 s, p<0.0001). In contrast, no difference was observed between FTBUT and NIBUTAvg values (8.6±6.2 s vs 8.3±5.5 s, p=0.655). The receiver operating characteristic curve analysis was performed to compare NIBUT and FTBUT in regards to other clinical tests (Ocular Surface Disease Index, ocular surface staining, blink interval, eye redness, corneal sensitivity, lid debris, Schirmer I test, tear osmolarity, meibum quality, meibum expressibility, lid hyperemia, tear meniscus height,. irregular lid margin, conjunctival hyperaemia, margin telangiectasia, lipid layer and meibomian gland drop-out). While FTBUT demonstrated results with area under the curve>0.6, neither NIBUTFirst nor NIBUTAvg showed significant results.

CONCLUSION

NIBUTFirst was shorter than FTBUT. Low correlation between NIBUT and FTBUT indicates that these diagnostic tests are not interchangeable. Other DED tests had correlation, though low, while NIBUT did not demonstrate correlation.

Performance and Safety of a Sodium Hyaluronate, Xanthan Gum, and Osmoprotectants Ophthalmic Solution in the Treatment of Dry Eye Disease: An Observational Clinical Investigation

INTRODUCTION

Dry eye disease (DED) is characterized by an imbalance in the tear film, resulting in symptoms such as dryness, redness, and discomfort. The management of DED involves tear supplements, medications, or surgery in severe cases. To evaluate the clinical performance and safety of a hypotonic ophthalmic solution containing sodium hyaluronate 0.2%, xanthan gum 0.2%, and osmoprotectants (glycine and betaine) for treating DED.

METHODS

This multicenter, prospective, observational clinical investigation included 35 subjects treated with one drop of the ophthalmic solution four times daily. Evaluations were conducted at baseline, on day 14, and at 1 and 3 months. The investigation assessed corneal and conjunctival fluorescein staining (NEI score), hyperemia index (Keratograph®), fluorescein tear film break-up time (TFBUT), best-corrected visual acuity, dry eye symptoms (SANDE), and quality of life (DEQS). Safety was monitored through adverse events, intraocular pressure measurements, and the Investigator Global Assessment of Safety.

RESULTS

Subjects were predominantly female (93.9%), with an average age of 59.9 ± 13.8 years. The ophthalmic solution significantly reduced keratitis lesions with global NEI score decreasing from baseline at 1 month (- 6.67 ± 4.6, p = 0.001) and 3 months (- 7.61 ± 4.0 points; p = 0.001). Conjunctival hyperemia improved significantly after 1 month (- 0.34 ± 0.7 points; p = 0.027), while fluorescein tear film stability increased significantly at 1 (1.85 ± 3.1 s; p = 0.002) and 3 months (1.98 ± 3.4 s; p = 0.001). Symptoms also improved significantly (p = 0.001) at 1 and 3 months (- 29.37 ± 22.2 points and - 26.41 ± 24.0 points, respectively), as did quality of life (- 20.81 ± 15.6 points at 1 month and - 18.43 ± 19.3 points at 3 months; p = 0.001 for both). The safety profile was very good, with no adverse events (only mild ocular discomfort reported in 14.3% of subjects).

CONCLUSIONS

The ophthalmic solution effectively improved DED symptoms and signs, enhancing patients' quality of life while maintaining a good safety profile.

TRIAL REGISTRATION NUMBER

NCT05778942.

Evaluation of Meibography Findings and Ocular Surface Parameters in Children with Atopic Dermatitis Without Eye Complaints

BACKGROUND/OBJECTIVES

To evaluate the meibomian gland (MG) morphology and ocular surface parameters of children with atopic dermatitis (AD) without ocular symptoms.

MATERIALS AND METHOD

Forty-five eyes of 24 children with AD and 44 eyes of 27 healthy children were included in the study. Upper and lower eyelid meibography measurements were performed for all cases and the rate of MG loss and the amount of tortuosity were evaluated. A Schirmer 1 test, tear break-up time (TBUT) test, and corneal staining scoring (CSS) were applied to all cases.

RESULTS

MG loss in the upper eyelid was 15.51 ± 10.39% in the AD group, while it was 9.30 ± 5.30% in the control group (p = 0.002). MG loss in the lower eyelid was 15.79 ± 10.93% in the AD group, while it was 9.23 ± 6.90% in the control group (p = 0.002). The rate of tortuosity in 26-50% of the upper and lower eyelid MGs was significantly higher in the AD group than in the healthy control group (p = 0.002 and p = 0.007, respectively). The Schirmer 1 test values were 10.98 ± 3.89 in the AD group and 17.41 ± 3.73 in the healthy control group (p < 0.0001). The TBUT values were found to be 9.18 ± 1.99 in the AD group and 11.40 ± 1.82 in the healthy control group (p < 0.0001). The CSS result was found to be significantly higher in the AD group than in the control group (p = 0.001).

CONCLUSIONS

Significant MG loss was detected in patients with AD without eye complaints, which may cause the early deterioration of ocular surface parameters. We believe that close follow-up examinations of children with AD in terms of ocular surface complications may be necessary.

The effect of botulinum neurotoxin A injections on meibomian glands and dry eye

PURPOSE

To assess the influence of Botulinum neurotoxin A (BoNT-A) injection on meibomian gland function and dry eye in patients diagnosed with Blepharospasm (BPS) and Hemifacial spam (HFS).

METHODS

Adult patients aged 18 years or older who suffer from periocular dystonia, and were treated with BoNT-A injections, were recruited in this interventional prospective study between 2023 and 2024. Each patient was followed up for a period of three months. The following parameters were compared at baseline, 14 and 90 days post BoNT-A injections: Visual acuity, meibography, tear break up time (TBUT), Schirmer test, meibum expression, tear meniscus height, fluorescein corneal staining, meibomian gland dysfunction (MGD) grading, and ocular surface disease index (OSDI). In addition, patients underwent subjective quality of life questionnaire for BPS and HFS.

RESULTS

Thirty-six eyes of twenty-six patients were included in this study. The mean age ±SD was 59 ± 17.33 years. There was a significant statistical difference in vascular changes on the lid margin, TBUT, corneal and conjunctival fluorescein staining and meibum expression (P < 0.001 in all). The differences were statistically significant when compared to baseline vs visit 2, and visit 2 vs visit 3 (p-value<0.05). Jankovic rating scale and HFS score improved significantly between the time periods (P < 0.001 in both). There was no significant difference in meibomian gland loss, tear meniscus height, Schirmer test, and OSDI.

CONCLUSION

BoNT-A injection is an effective treatment for periocular dystonia, but it worsens ocular surface and dry eye disease. Moreover, it affects the meibomian glands by disturbing their secretion.

Prospective Study of Corneal Sensitivity in Patients Treated With Proton Therapy for Extraocular Tumors

INTRODUCTION

Several cases of radio-induced neurotrophic keratitis had been observed after proton therapy delivering a mean corneal dose of ≥50 GyRBE. We conducted a prospective exploratory study to assess corneal sensitivity in subsequent patients undergoing proton therapy for cephalic extraocular tumors.

MATERIAL AND METHODS

Forty-three patients (85 eyes) treated with high-energy proton therapy were included in this prospective, single-center, observational cohort study. All patients had their corneal sensitivity measured using Cochet-Bonnet esthesiometer, before and average 6 months after irradiation. Ocular surface was clinically assessed for stromal opacity, corneal thinning, corneal perforation, superficial punctate keratitis graded according to Oxford classification, and tear break-up time. Cornea and extraocular sensitive innervation structures of cornea were contoured and their dose metrics assessed.

RESULTS

No severe corneal damage was detected. Corneal sensitivity, superficial punctate keratitis according to Oxford classification, and tear break-up time did not vary significantly after irradiation. The mean value of maximal dose to cornea and extraocular sensory innervation of cornea were 10.7 GyRBE and 42.0 GyRBE, respectively. Doses to cornea and its innervation structures were not associated with significant changes in corneal sensitivity (P = 0.423 and P = 0.614). A dose per fraction greater than 2 GyRBE was significantly associated (P = 0.033) with a decrease of corneal sensitivity after proton therapy.

CONCLUSIONS

This pilot study showed no excess risk of damage to corneal sensitivity 6 months after proton therapy, as doses to the cornea could be minimized. However, based on prior neurotrophic keratitis cases for corneal doses above 50 GyRBE, further investigation is needed to establish the impact of high-dose proton therapy on corneal sensitivity.

Therapeutic Effects of Umbilical Cord Serum for Dry Eye Disease: A Systemic Review and Meta-Analysis

INTRODUCTION

Dry eye disease (DED) is a prevalent ocular condition that significantly impacts quality of life. Umbilical cord serum (UCS) has emerged as a promising therapeutic option, but its efficacy requires further investigation. This systemic review and meta-analysis aimed to evaluate the therapeutic effects of UCS eye drops in the treatment of DED.

METHODS

A comprehensive literature search was conducted across multiple databases, including PubMed, Web of science, Embase, Science Direct, Cochrane Library, and China National Knowledge Network, to identify relevant clinical trials. The efficacy of UCS was assessed based on key outcome measures, such as the ocular surface disease index (OSDI), tear break-up time (TBUT), Schirmer I test, and corneal fluorescein staining scores. Meta-analyses were performed to pool the results, and the findings were presented in a forest plot.

RESULTS

Eight studies were included in the meta-analysis, with two relevant randomized controlled trials (RCTs) involving a total of 204 patients. Most of the included studies had a follow-up time of less than 2 months. The pooled results showed that UCS treatment significantly improved the OSDI, with a mean difference (MD) of -9.16 (95% confidence interval [CI], -12.0, -6.36) compared to baseline. Additionally, the TBUT values were higher in the UCS group, with an MD of 2.65 (95% CI, 0.93, 4.36). The Schirmer I test results showed an improvement, with an MD of 1.18 (95% CI, 0.30, 2.06). The fluorescein staining score were also lower in the UCS treatment group, with an MD of -4.71 (95% CI, -5.72, -3.69).

CONCLUSION

This meta-analysis suggested that UCS eye drops had a beneficial therapeutic effect on DED, significantly improving the OSDI, TBUT, Schirmer I test, and corneal fluorescein staining scores. However, larger RCTs with longer follow-up periods were needed to further evaluate the long-term efficacy and safety of UCS in the management of DED.

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.

Evaluation of ocular surface inflammation and systemic conditions in patients with systemic lupus erythematosus: a cross-sectional study

OBJECTIVE

The cross-sectional study was designed to evaluate the association of ocular surface inflammation with systemic conditions in patients with systemic lupus erythematosus (SLE).

METHODS

The study enrolled 30 SLE patients and 30 controls. Ocular symptoms were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. Tear samples from all participants were collected for tear multi-cytokine and chemokine concentration analysis. All participants were assessed for dry eye disease (DED), including Schirmer I test, tear break-up time (TBUT), corneal fluorescein staining (CFS), meibomian gland secretion (MGS), lid-parallel conjunctival folds (LIPCOF), corneal clarity, and symblepharon. Besides, all participants were also examined for conjunctival impression cytology to measure the density of conjunctival goblet cells (CGCs). The peripheral blood indicators from SLE patients were also collected to measure the SLE-associated autoantibody specificities and systemic inflammatory indicators. Pearson and Spearman's analysis were uesd to examine the correlation between tear cytokines, CGCs, DED-related indicators, and systemic conditions.

RESULTS

The two groups were matched for age and gender in this study. 36.67% of eyes (11 in 30) of SLE patients and 13.33% of eyes (4 in 30) of controls were diagnosed with DED. OSDI scores, abnormal TBUT percentages, CFS percentages, and DED grading were all higher in SLE patients than in control group, while density of CGCs was lower. There were no significant differences in Schirmer I test, MGS, LIPCOF, corneal clarity, and symblepharon between SLE patients and controls. The levels of tear chemokine (C-X-C motif) ligand 11 (CXCL11) and cytokine interleukin-7 (IL-7) in patients with SLE were significantly higher than those in control group. Moreover, among SLE patients, the severity of DED and the level of tear chemokine CXCL11 were significantly positively correlated with SLE-associated autoantibody specificities.

CONCLUSION

Dry eye and tear cytokines and chemokines-mediated ocular surface inflammation persist in SLE patients and are associated with systemic conditions. Therefore, it is necessary for patients with SLE to combine systemic and ocular assessments.

Establishing the cutoff value of near visual acuity for assessment of early presbyopia

PURPOSE

There is limited evidence to evaluate the numerical cutoff point for detecting early presbyopia. Thus, we aimed to establish a clinically relevant optimal cutoff value of near visual acuity for detecting early presbyopia.

STUDY DESIGN

Prospective diagnostic accuracy study.

METHODS

We included consecutive individuals aged ≥ 20 years with a binocular-corrected distance visual acuity of ≥ 20/25 who did not undergo ophthalmic surgery between December 17, 2020 and December 19, 2021, at two healthcare facilities in Japan. Binocular distance-corrected near visual acuity at 40 cm, accommodative amplitude, awareness of presbyopia, and Near Activity Visual Questionnaire scores were examined. The optimal cutoff values of distance-corrected near visual acuity for diagnosing early presbyopia were evaluated using receiver operating characteristic plots.

RESULTS

Among 115 participants, 74 (64.3%) had presbyopia. The proportion of participants with no difficulty performing near-vision tasks decreased markedly when near visual acuity decreased to 20/20 (> 0.00 logMAR). A cutoff value of 0.00 logMAR for distance-corrected near visual acuity was optimal, showing high sensitivity of 56.76% and specificity of 92.68%, as opposed to the commonly used cutoff value of 0.40 logMAR (20/50; sensitivity, 9.46% and specificity, 100%) for diagnosing early presbyopia.

CONCLUSION

Near visual acuity of 0.00 logMAR (20/20) could be the optimal cutoff value for diagnosing early presbyopia.

Visual and ocular surface benefits of mini-scleral contact lenses in patients with chronic ocular graft-versus-host disease (GvHD)

Graft-versus-Host disease is a major complication of allogeneic stem cell transplantation. The eyes are a frequently affected organ with a severe dry eye disease being the hallmark manifestation. This retrospective study evaluates the effect of mini-scleral contact lenses on visual acuity, eye-related quality of life and the ocular surface. 62 eyes of 31 patients were included and visual acuity, ocular surface disease index (OSDI) questionnaire results and Oxford grades before and after mini-scleral lens fitting were compared. Median Snellen fraction with mini-scleral lenses was 20/25 (1st 20/30/3rd 20/20) compared to 20/40 median Snellen fraction with spectacles (1st 20/60/3rd 20/25). Median OSDI scores improved from 73 (1st 41.6/3rd 89) before fitting to 27 (1st 14.5/3rd 56) with mini-scleral lenses. Median Oxford grade decreased from 3 before mini-scleral lens fitting (1st 1/3rd 4.75) to 1 after mini-scleral lens fitting (1st 0/3rd 4). Median time of follow up was 717.5 days. Seven patients (22.6%) discontinued therapy with mini-scleral lenses. Mini-scleral lenses are beneficial for most patients with ocular GvHD as they improve visual acuity, eye-related quality of life and the integrity of the corneal epithelium.

Serial intravitreal injections in age-related macular degeneration patients from the dry eye disease perspective: a cross-sectional study

BACKGROUND

To evaluate the effects of serial intravitreal injections (IVI) on the ocular surface and meibomian glands in patients with neovascular age-related macular degeneration (nAMD).

METHODS

Patients receiving anti-vascular endothelial growth factor (anti-VEGF) agent injections for unilateral nAMD were included. Untreated fellow eyes served as the control group. All participants followed a pre-IVI asepsis protocol with povidone-iodine (PI). Ocular surface diseases index (OSDI) questionnaire scores, first and average non-invasive tear break-up time (fNITBUT and avgNITBUT), Schirmer-1 test results, corneal staining score (according to Oxford scale), meibomian gland (MG) loss rates of lower and upper eyelids were recorded four weeks after the last IVI.

RESULTS

Forty-two nAMD patients with a mean age of 63.3 ± 19.4 were included in the study. The mean OSDI score was 20.3 and the median of IVI number was 9 (6-22). There were no statistically significant difference between treated and untreated fellow eyes regarding fNITBUT (5.6 vs. 4.5, p = 0.872), avgNITBUT (6.2 vs. 7.2, p = 0.968), Shirmer-1 results (7 vs. 7, p = 0.854), corneal staining (0.3 vs. 0.2, p = 0.341), lower and upper MG loss rate (29.3 vs. 28.4, p = 0.162, and 27.1 vs. 26.9, p = 0.476, respectively). Only significant correlation was observed between age with lower and upper MG loss rate (r:0.396, p = 0.042, and r:0.365, p = 0.047).

CONCLUSION

The results of the present study demonstrated that serial IVI of anti-VEGF agents with PI asepsis is well tolerated by nAMD patients in terms of ocular surface, MG loss and DED measurements.

Classification of dry eye disease subtypes

PURPOSE

The current subclassifications of dry eye disease (DED) are aqueous deficient (ADDE) and evaporative (EDE) forms, but there lacks consistency in the clinical characteristics used to define each of these. This study used clinical data to inform cut-off values for the subclassification of ADDE and EDE, to allow more consistent study of the epidemiology of both DED subtypes.

METHODS

The study enrolled 261 residents from the UK, extracted from a cohort with demographics representing the population (mean 42.4 ± 18.7 years, 56 % females). The TFOS DEWS II diagnostic criteria were used to identify those with DED. Meibomian gland loss/drop-out (from meibography), lipid layer thickness (LLT - from interferometry graded on the Guillon-Keeler scale), and tear meniscus height (TMH - Keratograph 5M) along with tear evaporation (Delfin Vapometer) were used to characterise the subclassification. The Dry Eye Risk Factor Survey was used to assess risk factors associated with each DED subtype.

RESULTS

Compared to individuals who were not diagnosed with DED, EDE was characterized by signs of meibomian gland loss of > 28 %, LLT grade < 3 and tear evaporation > 46 g/m2/h. In contrast, ADDE was best characterized by a reduced TMH < 0.2 mm. Based on these criteria, the prevalence of ADDE was 6.2 %, EDE was 64.2 %, and 11.1 % exhibited features of both ADDE and EDE, with 18.5 % unclassified despite having a DED diagnosis. Contact lens wear and computer use were risk factors for ADDE (p < 0.05), whereas age was a positive risk factor for EDE (p < 0.01). Meibomian gland loss (occurring in 27.9 %) was the most commonly observed sign in EDE.

CONCLUSIONS

Data driven-classification of DED confirms that the evaporative form is most prevalent and identified that in a generalisable UK population, ADDE alone occurs only in approximately 1 in 16 cases of DED.

The Effect of Topical Rebamipide 2% in Managing Dry Eye Following Cataract Surgery

Purpose: To evaluate the potential advantages of using topical rebamipide 2% to manage dry eye following cataract surgery.Methods: Patients who underwent cataract surgery (phacoemulsification and intraocular lens insertion) were evaluated for dry eye 1 week postoperatively. Randomly selected patients were divided into the rebamipide group, who received 2% rebamipide eye drops, and the control group, who did not receive rebamipide. Various dry eye-related tests, including Schirmer’s test, the tear break-up time (TBUT), ocular surface staining, tear film osmolarity, tear lipid layer thickness, and the ocular surface disease index (OSDI) were performed in both groups 1 week, and 1 and 2 months postoperatively.Results: In the rebamipide group, we observed significant improvement in TBUT, the ocular surface staining score, and OSDI at 2 months postoperatively, as compared to 1 week (<i>p</i> = 0.002, 0.014, and 0.013, respectively). Schirmer’s test, tear film osmolarity, and tear lipid layer thickness remained unchanged in the rebamipide group. Throughout the entire follow-up period, the rebamipide group had a significantly prolonged TBUT (1 month: <i>p</i> = 0.007, 2 months: <i>p</i> = 0.000), and lower ocular surface staining score (1 month: <i>p</i> = 0.000, 2 months: <i>p</i> = 0.000), as compared to the control.Conclusions: Following cataract surgery, the use of rebamipide eye drops produced improvements in TBUT, ocular surface staining scores, and OSDI. This suggests that rebamipide offers benefits in managing dry eye that can occur after cataract surgery.

Effect of laughter exercise versus 0.1% sodium hyaluronic acid on ocular surface discomfort in dry eye disease: non-inferiority randomised controlled trial

OBJECTIVE

To assess efficacy and safety of laughter exercise in patients with symptomatic dry eye disease.

DESIGN

Non-inferiority randomised controlled trial.

SETTING

Recruitment was from clinics and community and the trial took place at Zhongshan Ophthalmic Center, Sun Yat-sen University, the largest ophthalmic centre in China, between 18 June 2020 to 8 January 2021.

PARTICIPANTS

People with symptomatic dry eye disease aged 18-45 years with ocular surface disease index scores ranging from 18 to 80 and tear film break-up time of eight seconds or less.

INTERVENTIONS

Participants were randomised 1:1 to receive laughter exercise or artificial tears (0.1% sodium hyaluronic acid eyedrop, control group) four times daily for eight weeks. The laughter exercise group viewed an instructional video and participants were requested to vocalise the phrases "Hee hee hee, hah hah hah, cheese cheese cheese, cheek cheek cheek, hah hah hah hah hah hah" 30 times per five minute session. Investigators assessing study outcomes were masked to group assignment but participants were unmasked for practical reasons.

MAIN OUTCOME MEASURES

The primary outcome was the mean change in the ocular surface disease index (0-100, higher scores indicating worse ocular surface discomfort) from baseline to eight weeks in the per protocol population. The non-inferiority margin was 6 points of this index score. Main secondary outcomes included the proportion of patients with a decrease from baseline in ocular surface disease index score of at least 10 points and changes in dry eye disease signs, for example, non-invasive tear break up time at eight weeks.

RESULTS

299 participants (mean age 28.9 years; 74% female) were randomly assigned to receive laughter exercise (n=149) or 0.1% sodium hyaluronic acid (n=150). 283 (95%) completed the trial. The mean change in ocular surface disease index score at eight weeks was -10.5 points (95% confidence interval (CI) -13.1 to -7.82) in the laughter exercise group and -8.83 (-11.7 to -6.02) in the control group. The upper boundary of the CI for difference in change between groups was lower than the non-inferiority margin (mean difference -1.45 points (95% CI -5.08 to 2.19); P=0.43), supporting non-inferiority. Among secondary outcomes, the laughter exercise was better in improving non-invasive tear break up time (mean difference 2.30 seconds (95% CI 1.30 to 3.30), P<0.001); other secondary outcomes showed no significant difference. No adverse events were noted in either study group.

CONCLUSIONS

The laughter exercise was non-inferior to 0.1% sodium hyaluronic acid in relieving subjective symptoms in patients with dry eye disease with limited corneal staining over eight weeks intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04421300.

Optimizing the methodology for the assessment of bulbar conjunctival lissamine green staining

SIGNIFICANCE

When using lissamine green for bulbar conjunctival evaluation, the most staining was observed with two applications of the same strip in the same eye, wetted with a drop of saline. The first application was 5 seconds after wetting the strip, and the second was 1 minute later, followed by immediate viewing. This suggests that bulbar staining should be viewed before the lid wiper region.

PURPOSE

This study aimed to optimize the assessment of lissamine green staining of the bulbar conjunctiva by investigating the application technique and subsequent observation period.

METHODS

Twenty-two participants with dry eye (as defined by the Tear Film and Ocular Surface Society Dry Eye Workshop II) were recruited to trial five application methods in randomized order: (1) application immediately after wetting a single strip, (2) application 5 seconds after wetting a single strip, (3) application 10 seconds after wetting a single strip, (4) consecutive single application of sodium fluorescein followed by lissamine green 5 seconds after wetting, and (5) two applications using the same lissamine green strip 5 seconds after wetting, 1 minute apart. Slit-lamp photography of the conjunctiva was performed immediately following application and at 30, 60, 90, and 300 seconds after application. Three experienced (masked) practitioners independently quantified the visible punctate spots and graded the staining intensity within the images in a random order.

RESULTS

Values for punctate spot count ( F = 6.29, p<0.0001) and lissamine green staining intensity ( F = 6.29, p<0.0001) varied significantly between the different application methods. Using two applications of the same lissamine green strip, 1 minute apart, in the same eye resulted in the greatest values for both punctate spot count and lissamine green staining intensity. Lissamine green staining decreased with time for both spot count ( F = 18.87, p<0.0001) and lissamine green staining intensity ( F = 11.33, p<0.0001), with the most staining found immediately after application followed by a gradual decline. There was no evidence of any interaction effect between time and application method for either measure (p>0.05 for both).

CONCLUSIONS

The optimal approach for assessing bulbar conjunctival lissamine green staining involves two applications of a whole infused drop resting on the same strip for 5 seconds, applied 1 minute apart. The ocular surface should be viewed immediately after application to maximize the conjunctival staining observed.

Tear film assessment before and after phacoemulsification in patients with age-related cataracts

BACKGROUND

The study aims to assess the tear film before and after phacoemulsification in patients with age-related cataracts.

METHODS

A prospective observational study of 41 age-related cataract patients undergoing phacoemulsification procedure. Tear Film Break-Up Time (TBUT), Tear Film Meniscus Height (TMH), Meibomian glands (MG), and Lipid Layer Thickness (LLT) were assessed by a non-invasive Dry Eye Diagnostic System. All measurements were taken preoperatively, one week, one month, and three months postoperatively. The Marginal homogeneity and The Cochran Q tests were used in the statistical analysis.

RESULTS

The value of Non-Invasive Break-Up Time (NITBUT) was statistically significantly lower at one week (7.15 ± 3.31), one month (7.61 ± 3.41), and three months (7.66 ± 3.36) postoperatively than preoperatively (10.71 ± 2.71), p < 0.001. The Non- Invasive Tear Meniscus Height (NITMH) was significantly lower at one week (0.18 ± 0.0), one month (0.20 ± 0.09), and three months (0.20 ± 0.09) postoperatively than preoperatively (0.30 ± 0.113) p < 0.001. By the first month, both (NITBUT) and (NITMH) improved significantly compared to the first post-operative week. There was no statistically significant difference between one month and three months. The (NITMH) improved to a healthy level of ≥ 0.2 mm by the first month through the third month. Both (NITBUT) and (NITMH) did not reach the baseline by the third month. The meibomian glands and the lipid layer thickness had the same preoperative grade distribution without changes.

CONCLUSION

Phacoemulsification surgery can cause post-operative deterioration in the tear film, which starts within a week of the procedure, followed by gradual recovery over the next weeks and months. The phacoemulsification procedure mainly affects the tear break-up time and tear meniscus height. Both the lipid layer and meibomian glands are not affected.

A Possible Reciprocal Relationship Between Myopia and Dry Eye Disease in Japanese Teenagers

Purpose

To investigate the relationship between dry eye disease (DED) and myopia in Japanese teenagers.

Methods

This clinic-based, retrospective, cross-sectional study assessed DED condition in 10- to 19-year-old teenagers presenting at Japanese eye clinics. They included 106 high myopic patients (HM; mean age, 16.4 ± 2.2 years), 494 mild myopic patients (15.0 ± 2.6 years) and 82 non-myopic teenagers (NM; 13.8 ± 2.6 years). Subjective refraction and anisometropia were measured. Myopia grade was classified as HM (≤ -6.00 D), MM (> -6.00 D, < -0.50 D), or NM (≥ -0.5 D). The presence of DED-related symptoms including dryness, irritation, pain, fatigue, blurring and photophobia were assessed through a questionnaire. Tear film break-up time (BUT) and fluorescein corneal staining were investigated. Comparison among three groups and regression analysis of myopic error and other variables were conducted.

Results

Anisometropia and astigmatic error were greatest in the HM group compared with the other groups (p < 0.001). The HM group reported less photophobia (p < 0.001) and less pain (p = 0.039) compared with the NM group. Regression analysis revealed that myopic error was correlated with astigmatic error (β = -0.231, p <0.001), anisometropia (β = -0.191, p <0.001), short BUT (β = -0.086, p = 0.028) and the presence of diagnosed DED (β = -0.112, p = 0.003). Dryness (β = -0.127 p = 0.004), photophobia (β = 0.117, p = 0.002) and pain (β = 0.084, p = 0.034) correlated with myopic error.

Conclusion

This study associated clinical findings of DED in HM teenagers. The present results suggest DED might be associated with myopia, possibly in a reciprocal relationship.

Homoeopathic eye drops in the treatment of mild-to-moderate dry eye disease: Randomised, prospective, multicentre, single-masked study

INTRODUCTION

To compare the efficacy and safety of a homeopathic eye drop medicinal product (Homeoptic®) with 0.9% sodium hydrochloride eye drops (Larmabak®) in patients with mild-to-moderate dry eye disease (DED).

METHODS

Prospective, single-masked, observer-blinded, multicentre study on adult patients. Non-inferiority primary endpoint of the relative change between treatment groups in a composite Visual Analogue Scale (VAS) score covering five symptoms of DED, namely pain, itching, sensation of dry eye, impression of foreign body presence and burning, after 30 days of treatment. Details of all Adverse Events (AEs) were recorded and analysed.

RESULTS

Ninety three patients were randomised to each treatment arm. At Day 30, the mean VAS symptom score was 26.0 ± 18.8 in the Homeoptic® group and 32.8 ± 21.2 Larmabak® group. Homeoptic® was demonstrated to be non-inferior to Larmabak®: the mean treatment difference of -7 being below the 10 mm upper limit of the 95% CI ([-12.9; -1.0]) pre-set as significant. The superiority of Homeoptic® over Larmabak® was then established with detection of a significant difference between the two treatment groups (p = 0.022). Significant differences between the treatment groups in favour of Homeoptic® were also detected in isolated VAS scores for the symptoms dry eye sensation (p = 0.009) and burning (p = 0.004). Results of ocular surface staining tests to estimate corneal and conjunctival damage as well as patient satisfaction were also significantly in favour of Homeoptic®. No new safety concerns were identified.

CONCLUSION

Homeoptic® is more effective than Larmabak® at relieving the symptoms of DED and constitutes an effective treatment for mild-to-moderate DED.

Lipids from ocular meibum and tears may serve as biomarkers for depression and post-traumatic stress disorder

BACKGROUND

There is a need to develop biomarkers for diagnosis and prediction of treatment responses in depression and post-traumatic stress disorder (PTSD).

METHODS

Cross-sectional study examining correlations between tear inflammatory proteins, meibum and tear sphingolipids, and symptoms of depression and PTSD-associated anxiety. Ninety individuals filled depression (Patient Health Questionnaire 9, PHQ-9) and PTSD-associated anxiety (PTSD Checklist-Military Version, PCL-M) questionnaires. In 40 patients, a multiplex assay system was used to quantify 23 inflammatory proteins in tears. In a separate group of 50 individuals, liquid chromatography-mass spectrometry was performed on meibum and tears to quantify 34 species of sphingolipids, encompassing ceramides, monohexosyl ceramides and sphingomyelins.

RESULTS

The mean age of the population was 59.4 ± 11.0 years; 89.0% self-identified as male, 34.4% as White, 64.4% as Black, and 16.7% as Hispanic. The mean PHQ-9 score was 11.1 ± 7.6, and the mean PCL-M score was 44.3 ± 19.1. Symptoms of depression and PTSD-associated anxiety were highly correlated (ρ =0.75, p < 0.001). Both PHQ9 and PCL-M scores negatively correlated with multiple sphingolipid species in meibum and tears. In multivariable models, meibum Monohexosyl Ceramide 26:0 (pmol), tear Ceramide 16:0 (mol%), meibum Monohexosyl Ceramide 16:0 (mol%), and tear Ceramide 26:1 (mol%) remained associated with depression and meibum Monohexosyl Ceramide 16:0 (mol%), meibum Monohexosyl Ceramide 26:0 (pmol), tear Sphingomyelin 20:0 (mol%), and tear Sphingosine-1-Phosphate (mol%) remained associated with PTSD-associated anxiety.

CONCLUSIONS

Certain meibum and tear sphingolipid species were related to mental health indices. These interactions present opportunities for innovative diagnostic and therapeutic approaches for mental health disorders.

Standardized clinical evaluation of dry anophthalmic socket syndrome in a real-world approach

PURPOSE

To assess which signs and eye prosthesis care habits are related to subjective discomfort in patients with dry anophthalmic socket syndrome (DASS), using standardized tools from daily practice.

METHODS

62 anophthalmic sockets were compared with their healthy fellow eye using the Standard Patient Evaluation of Eye Dryness (SPEED) score. The correlations between SPEED questionnaire and the prosthesis care, discharge characteristics score, conjunctival inflammation score, meibomian gland dysfunction (MGD) scores and Schirmer I test were studied.

RESULT

The anophthalmic sockets group achieved a higher SPEED test score (p < 0.01), discharge score (p < 0.01), conjunctival inflammation score (p < 0.01), MGD scores (p < 0.01) and lower Schirmer I test (p < 0.01) compared with their fellow, healthy eye. Patients with a prosthesis replacement of one year or less, those with a current fit time of one year or less and those with a cleaning frequency above one month reported better SPEED, (p < 0.01), conjunctiva inflammation (p < 0.01) and MGD scores (p < 0.01).

CONCLUSION

Most anophthalmic patients suffer mild to severe DASS, which seems related to discharge, conjunctival inflammation and MGD. Moreover, certain practices related to the care of the prosthesis such as replacing with a frequency lower than yearly, current fitting time inferior to one year and a removing and cleaning regime above one month, were related to a lower discomfort sensation, conjunctival inflammation and MGD. Clinicians should consider the DASS when facing patients with anophthalmic socket and discomfort symptoms.

Dry Eye and Some Related Factors in Patients with Type 2 Diabetic Nephropathy: A Cross-Sectional Study in Vietnam

Aim

To determine the prevalence of dry eye (DE) and some related factors in patients with type 2 diabetic nephropathy (T2DN).

Methods

We performed a cross-sectional study on 338 people, who were divided into 2 groups: 169 T2DN patients and 169 patients diagnosed with type 2 diabetic mellitus (T2DM) without renal complications as a control group. The Ocular Surface Disease Index (OSDI) and test fluorescein tear-film break-up time (TBUT) were done in all 338 subjects. Patients with OSDI scores < 13 and TBUT values equal to or under 10 seconds were diagnosed with dry eye.

Results

The prevalence of DE in T2DN patients was significantly higher than T2DM group (55.6% versus 37.3%). The T2DN groups with dry eye had a median duration of DM, the proportion of hypertension, peripheral nerve complications, anemia, proportion of using insulin, and concentration of plasma glucose, HbA1C, urea, creatinine, CRP-hs significantly higher than those of T2DN without dry eye. Advanced age, high HbA1C level, and decreased eGFR were independent factors associated with dry eye in T2DN patients.

Conclusion

Dry eye was a common condition associated with advanced age, high HbA1C levels, and decreased GFR in T2DN patients.

Evaluating Moisture Migration in Schirmer Test Strips: Exploring Brand-Specific Variations and Introducing Calibration and Conversion Methods

PURPOSE

Schirmer test results are widely used for ocular surface disease assessment, but Schirmer strips are not standardized. We compare the characteristics and tear volume with millimeter moisture migration in different brands of Schirmer strips and introduce methods for volume-based, brand-independent calibration.

METHODS

Physical parameters of Haag-Streit, EagleVision, TearFlo, Contacare, and MIPL/A6 Schirmer strip brands were compared. Schirmer strip millimeter moisture migration distances were assessed 5 minutes after application of incremental microliter volumes of human tears. Linear regression analysis of data points from each Schirmer strip brand was performed, and the root-mean-square deviation of data points to the best-fit linear regression was calculated. Calibration correction was performed by converting migration distance to the corresponding tear volume. A reference table and calibration method formulas were created.

RESULTS

Schirmer strips differed in design, shape, and manufacturing precision. Strip width, weight, and length were different between the 5 brands ( P < 0.05). A wide range of Schirmer strip moisture migration values for identical tear volumes was observed among brands. Statistical measurement resulted in a root-mean-square deviation of 2.9 mm for all data points from all brands. Millimeter to volume and weight to volume-based calibration correction methods resulted in a 2.2- and 3.1-fold measurement error reduction, respectively.

CONCLUSIONS

Our findings highlight the lack of standardization among different brands of Schirmer strips, raising concerns about potential sources of unintentional measurement errors. We propose volume-based Schirmer strip calibration methods and conversion of millimeter to microliter results to achieve brand-independent results and improve Schirmer test accuracy.

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.

Sex Differences in the Prevalence of Meibomian Gland Dysfunction: A Mini Review

PURPOSE

In this review, we aimed to investigate the literature on sex-specific prevalence of meibomian gland dysfunction (MGD) and to determine whether women or men are more at risk for MGD.

METHODS

A search was conducted on PubMed using the terms: (Sex OR Gender OR prevalence) AND (Meibomian gland).

RESULTS

Twenty-four relevant studies on MGD prevalence were identified, including 10 population-based and 14 hospital-based studies. Among the population-based studies, five studies reported higher rates among men, three studies found no differences, and one study observed higher rates among women. In the hospital-based studies, 10 studies reported no difference, two found higher rates among men, and one found higher among women. In the reviewed literature, there was a considerable variation between studies in terms of quality, sample size, age ranges, diagnostic criteria.

CONCLUSIONS

While most of the population-based studies suggest a higher prevalence among men, the majority of clinic-based studies show no significant difference. Further research with larger samples and standardized criteria is needed to determine whether men are indeed more susceptible to MGD.

Efficacy of a new refractive multifocal contact lens for presbyopia

This prospective single-arm study aimed to evaluate the clinical efficacy and safety of a refractive multifocal contact lens for the correction of presbyopia in 22 patients. The participants underwent clinical examinations before and 1 week after wearing a refractive multifocal contact lens (OptaCon ZOOM). The primary endpoints were the corrected distance visual acuity (CDVA) and distance-corrected near visual acuity (DCNVA). Defocus curve, contrast sensitivity, and ocular surface disease index (OSDI) were analyzed. A slit-lamp examination was performed for safety analysis. Contact lens comfort and patient satisfaction were assessed using a questionnaire. No significant difference in CDVA was observed before and 1 week after refractive multifocal contact lens use (p = 0.127), whereas DCNVA was significantly improved after 1 week (p < 0.001). The contrast sensitivity was not significantly affected at any spatial frequency under mesopic or photopic conditions. OSDI was significantly increased (p = 0.023). The patient-reported satisfaction scores were 96.2, 91.9, and 85.0 out of 100 at far, intermediate, and near distances, respectively. No significant adverse events were observed. Refractive multifocal contact lenses improved near vision while maintaining distance vision in presbyopic patients, without compromising contrast sensitivity. The study results suggest that OptaCon ZOOM can be considered safe and effective for the correction of presbyopia.

Association between systemic medication use and severity of dry eye signs and symptoms in the DRy eye assessment and management (DREAM) study

PURPOSE

Some systemic medications are reported to be associated with dry eye disease (DED), yet their associations with the severity of DED signs and symptoms are not well studied. To evaluate these associations, we performed a secondary analysis of data from the DRy Eye Assessment and Management (DREAM) Study.

METHODS

Participants (N = 535) were assessed for DED signs using tear break-up time (TBUT), Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, meibomian gland dysfunction (MGD), and tear osmolarity and DED symptoms using the Ocular Surface Disease Index (OSDI). We derived a composite signs severity score from the 6 DED signs and categorized participant-reported systemic medications into antidepressants, antihistamines, aspirin, corticosteroids, diuretics, nonsteroidal anti-inflammatory drugs, proton pump inhibitors, statins, vitamin D3, and medications for diabetes mellitus, hypertension, hypothyroidism, migraine, and seizure. Generalized linear models were used to compare DED symptom and sign scores between medication users and non-users, with adjustment for factors associated with DED severity.

RESULTS

Compared to non-users, antihistamine users had lower TBUT (p = 0.01) and higher OSDI score (p = 0.02); aspirin users had lower TBUT (p = 0.02); corticosteroid users had lower TBUT (p = 0.02), lower Schirmer test scores (p = 0.03), higher cornea fluorescein staining (p = 0.01), higher composite severity score (p = 0.01), and higher OSDI score (p = 0.03); seizure medication users had higher composite severity score (p = 0.02); vitamin D3 users had lower TBUT (p = 0.001) and greater MGD (p = 0.03); and diuretic users had less MGD (p = 0.03).

CONCLUSIONS

Certain systemic medications may be associated with more severe DED. This may guide prescription practices in patients with DED.

Need to Increase the Number of Intense Pulsed Light (IPL) Treatment Sessions for Patients with Moderate to Severe Meibomian Gland Dysfunction (MGD) Patients

PURPOSE

To evaluate whether patients with moderate-to-severe meibomian gland dysfunction (MGD) will benefit from increasing the number of intense pulsed light (IPL) treatment sessions.

METHODS

Ninety Asian adult with MGD (stages 3-4) were enrolled in this retrospective study. In Group1, 30 patients completed the five-session IPL treatment, 63.33% of which also received meibomian gland expression (MGX). In Group 2, 60 patients received three-session IPL treatment, 60.0% of which also accepted MGX. Both intragroup and intergroup analyses were conducted.

RESULTS

The population characteristics, clinical baseline characteristics and therapeutic regimen were comparable between Group1 and Group2. The symptoms and most clinical indices improved after IPL treatment finished in both two groups. No statistical difference was found in any improvement level of all symptomatic and physical indices, including the Ocular surface disease index, tear break-up time, Demodex, corneal staining, meibum quality, meibomian gland expressibility, and MGD stage (all p ≥ 0.05) between the two groups at any time, not only month by month, but also at the terminal visit. However, the response rate of Group1 after the five-session treatment (70.00%) was increased compared to that of Group2 after the three-session treatment (63.33%).

CONCLUSIONS

Increasing the number of IPL sessions is beneficial for patients with moderate to severe MGD to increase the response rate of treatment, rather than the improvement level. However, there is no need for patients who respond well to a routine number of IPL treatments to undergo additional IPL sessions.

FL-41 Tint Reduces Activation of Neural Pathways of Photophobia in Patients with Chronic Ocular Pain

PURPOSE

To assess the therapeutic effect of tinted lenses (FL-41) on photophobia and light-evoked brain activity using functional magnetic resonance imaging (fMRI) in individuals with chronic ocular surface pain.

DESIGN

Prospective case series.

METHODS

25 subjects from the Miami veterans affairs (VA) eye clinic were recruited based on the presence of chronic ocular pain, dry eye symptoms, and photophobia. Using a 3T MRI scanner, subjects underwent 2 fMRI scans using an event-related design based on light stimuli: one scan while wearing FL-41 lenses and one without. Unpleasantness ratings evoked by the light stimuli were collected after each scan.

RESULTS

With FL-41 lenses, subjects reported decreased (n = 19), maintained (n = 2), or increased (n = 4) light-evoked unpleasantness ratings. Group analysis at baseline (no lens) revealed significant light evoked responses in bilateral primary somatosensory (S1), bilateral secondary somatosensory (S2), bilateral insula, bilateral frontal pole, visual, precuneus, paracingulate, and anterior cingulate cortices (ACC) as well as cerebellar vermis, bilateral cerebellar hemispheric lobule VI, and bilateral cerebellar crus I and II. With FL-41 lenses, light-evoked responses were significantly decreased in bilateral S1, bilateral S2, bilateral insular, right temporal pole, precuneus, ACC, and paracingulate cortices as well as bilateral cerebellar hemispheric lobule VI.

CONCLUSION

FL-41 lenses modulated photophobia symptoms in some individuals with chronic ocular pain. In conjunction, FL-41 lenses decreased activation in cortical areas involved in processing affective and sensory-discriminative dimensions of pain. Further research into these relationships will advance the ability to provide precision therapy for individuals with ocular pain.

Genome Wide Association Study of Neuropathic Ocular Pain

Purpose

To conduct a genome-wide association study (GWAS) of individuals with neuropathic ocular pain (NOP) symptoms to identify genomic variants that may predispose to NOP development.

Design

Prospective study of individuals with NOP.

Participants

Three hundred twenty-nine patients recruited from the Miami Veterans Affairs eye clinic.

Methods

The Neuropathic Pain Symptom Inventory modified for the eye (NPSI-Eye) was completed to calculate a NPSI-Eye-Sub-Score (summed ratings of burning and wind sensitivity) as an indicator of NOP severity. A GWAS was performed for the NPSI-Eye-Sub-Score with a significance threshold of P < 5 × 10-8. A gene-based analysis was performed using the multimarker analysis of genomic annotation software (in the functional mapping and annotation of GWAS online platform). The 13 865 778 single nucleotide polymorphisms (SNPs) from our GWAS analysis were mapped to 10 834 protein coding genes, and significant genes were run through gene set enrichment analysis.

Main Outcome Measures

Identification of SNPs and protein products that may be associated with the development of NOP.

Results

One hundred seventy-one SNPs reached a threshold of P < 10-5, of which 10 SNPs reached the suggestive level of significance of P < 5 × 10-7 and 1 SNP met our genome-wide significance threshold of P < 5 × 10-8. This lead SNP, rs140293404 (P = 1.23 × 10-8), is an intronic variant found within gene ENSG00000287251 coding for transcript ENST00000662732.1. Rs140293404 is in linkage disequilibrium with exon variant rs7926353 (r2 > 0.8) within ENSG00000279046 coding for transcript ENST00000624288.1. The most significant genes from gene-based tests were matrix metalloproteinase-19 (MMP19) (P = 1.12 × 10-5), zinc finger RNA-binding motif and serine/arginine rich-1 (ZRSR1) (P = 1.48 × 10-4), CTC-487M23.8 (P = 1.79 × 10-4), receptor expression-enhancing protein-5 (REEP5) (P = 2.36 × 10-4), and signal recognition particle-19 (SRP19) (P = 2.56 × 10-4). From gene set enrichment analysis, the sensory perception (false discovery rate = 6.57 × 10-3) and olfactory signaling (false discovery rate = 1.63 × 10-2) pathways were enriched with the most significant genes.

Conclusions

Our GWAS revealed genes with protein products that may impact sensory perception, lending biological plausibility to a role for SNPs identified by our GWAS in the development of NOP. A better understanding of the biological relevance of these genes and pathways in the pathophysiology associated with NOP may facilitate future novel mechanism-based treatments.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Regional Conjunctival Differences in Glycocalyx Mucin Expression in Dry Eye and Normal Subjects

Purpose

To compare regional conjunctival expression of membrane-associated mucins (MAMs) MUC1, MUC4, and MUC16 in normal and dry eye (DE) subjects.

Methods

Adults with and without signs and symptoms of DE were recruited. Impression cytology was performed to collect MAMs from four bulbar and upper eyelid palpebral conjunctival regions of both eyes. After protein extraction, samples from both eyes of a single subject were pooled by region, and expression was analyzed using a capillary electrophoresis nano-immunoassay system. The chemiluminescence intensity of each antigen binding signal was calculated after normalization to the total protein amount. Statistical analyses were conducted using GraphPad Prime 9.

Results

Samples from thirteen to sixteen DE and seven to eleven normal subjects were analyzed. In normal samples, MUC1 expression from the nasal bulbar conjunctiva was significantly greater than superior (P = 0.004) and inferior (P = 0.005). In DE samples, MUC1 expression was highest superiorly. Significant differences in MUC4 and MUC16 expression were not seen in normal samples. MUC4 and MUC16 expression was upregulated superiorly (P < 0.0001) and inferiorly (P < 0.0001) in DE compared with those regions in normal samples.

Conclusions

Although MAMs form a hydrophilic barrier called the glycocalyx, each mucin may have unique functions that are currently unexplored. All MAMs were expressed in the upper palpebral conjunctiva. Increased MUC1 expression nasally in healthy subjects suggests a functional need for increased protection. When comparing DE with normal eyes, upregulation of MUC1 superiorly, and in both MUC4 and MUC16 both superiorly and inferiorly, may indicate a need to decrease eyelid friction during blinking, especially in DE.

Relation Between Corneal Dendritic Cell Density and Tear Film Stability in Patients with Epidemic Keratoconjunctivitis Associated Dry Eye

PURPOSE

To clarify the ocular surface features of patients with recent history of epidemic keratoconjunctivitis (EKC) and the relation between corneal dendritic cells (DCs) and ocular discomfort.

METHODS

Normal controls (NC) and dry eye (DE) patients without EKC were recruited. Patients with recent EKC history (onset >4 weeks, but <20 weeks) were recruited as EKC + DE group (with dry eye) or EKC-DE group (without dry eye). Ocular surface disease index (OSDI) questionnaire, tear film parameters including lipid layer thickness, first tear break-up time (fBUT), average tear break-up time (aBUT), tear meniscus height and Schirmer I test, meibomian gland parameters, and in vivo corneal confocal microscopy were evaluated.

RESULTS

50 subjects in the NC group, 83 patients in the DE group, 76 patients in the EKC + DE group, and 38 patients in the EKC-DE group were included. Compared with the NC, DE, and EKC-DE groups, the EKC + DE group represented higher OSDI, lid margin, and meibum score (p < 0.05). In the EKC + DE group, the tear volume (10.5 ± 3.7 mm) was significantly higher than in the DE group (8.1 ± 2.8 mm, p < 0.001). The DC density in the EKC + DE group (29.98 ± 15.38 cells/image) was significantly higher than in NC, DE, and EKC-DE groups (4.68 ± 4.05 cells/image) (p < 0.001). The DC density was positively correlated with OSDI, lid margin, and meibum score (all p < 0.01) while inversely correlated with fBUT, aBUT (all p < 0.001) in the EKC + DE group.

CONCLUSIONS

Corneal DC density significantly correlates to ocular discomfort and tear film instability in patients with recent EKC history who suffer from DE without aqueous tear deficiency.

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.

Evaluation of Dry Eye Severity and Ocular Surface Inflammation in Patients with Pemphigus and Pemphigoid

PURPOSE

To evaluate ocular surface involvement, tear cytokine levels, and histopathological changes in pemphigus and pemphigoid patients.

METHODS

A total of 22 patients (15 pemphigus and 7 pemphigoids) and 21 non-diseased controls were enrolled in our study. All participants underwent ocular surface evaluation, which included ocular surface disease index test, slit lamp observation, dry eye-related examination, tear multicytokine analysis, and conjunctival impression cytology.

RESULTS

Pemphigus and pemphigoid patients presented much more severe conjunctivochalasis, corneal epithelial defects, corneal opacity, symblepharon   and dry eye. Severe ocular surface squamous metaplasia and a significant increase of tear macrophage inflammatory protein-1beta, tumor necrosis factor-alpha, interleukin (IL)-1β, IL -6, and IL-8 occurred in pemphigus and pemphigoid patients.

CONCLUSIONS

Our results revealed that ocular surface inflammation and dry eye persist in most pemphigus and pemphigoid patients, and do not occur in parallel with the systemic course. Regular ophthalmological examinations and local anti-inflammatory should be provided for pemphigus and pemphigoid patients.

Using machine learning model explanations to identify proteins related to severity of meibomian gland dysfunction

Meibomian gland dysfunction is the most common cause of dry eye disease and leads to significantly reduced quality of life and social burdens. Because meibomian gland dysfunction results in impaired function of the tear film lipid layer, studying the expression of tear proteins might increase the understanding of the etiology of the condition. Machine learning is able to detect patterns in complex data. This study applied machine learning to classify levels of meibomian gland dysfunction from tear proteins. The aim was to investigate proteomic changes between groups with different severity levels of meibomian gland dysfunction, as opposed to only separating patients with and without this condition. An established feature importance method was used to identify the most important proteins for the resulting models. Moreover, a new method that can take the uncertainty of the models into account when creating explanations was proposed. By examining the identified proteins, potential biomarkers for meibomian gland dysfunction were discovered. The overall findings are largely confirmatory, indicating that the presented machine learning approaches are promising for detecting clinically relevant proteins. While this study provides valuable insights into proteomic changes associated with varying severity levels of meibomian gland dysfunction, it should be noted that it was conducted without a healthy control group. Future research could benefit from including such a comparison to further validate and extend the findings presented here.

[Chromatic Swept-Source Laser Scanning - Concept for a Cell-Resolving Confocal Laser Slit Lamp?]

BACKGROUND

The in vivo characterisation of corneal epithelial tissue morphology is of considerable importance for diagnosis, disease prognosis, and the development of a treatment strategy for ocular surface diseases. In contrast to many alternative methods, in vivo corneal confocal microscopy (CCM) not only provides a macroscopic description of the corneal tissue but also allows its visualisation with cellular resolution. However, the translation of CCM from research to clinical practice is significantly limited by the complex and still largely manual operation of available CCM systems. In addition, for cross-sectional images, and analogously to conventional slit lamp microscopy, volume data must be acquired in time-consuming depth scans due to the frontal orientation of the image field in CCM, from which depth slices can subsequently be calculated. The pure acquisition time is already in the range of seconds, and additionally, motion artefacts have to be corrected in a sophisticated way.

MATERIALS AND METHODS

This paper presents the concept and optics simulation of a new imaging technique based on a swept-source laser in combination with special chromatic optics. Here, the laser periodically changes its wavelength and is focused at different depths due to the wavelength-dependent aberration of the chromatic optics.

RESULTS

The optics simulation results promise good optical resolution at a total imaging depth of 145 µm.

CONCLUSION

The long-term goal is cell-resolving in vivo corneal confocal microscopy in real time with differently oriented sectioning directions.

Exploring Signs and Symptoms Associated with Meibomian Gland Dysfunction for Use as Clinical Trial Endpoints

Purpose: Dry eye disease is attributed to impaired tear production and/or evaporative dry eye. Evaporative dry eye is frequently associated with meibomian gland dysfunction (MGD). The objective of this study was to identify clinical study endpoints related to MGD. Methods: This 22-day, noninterventional, case-control clinical study involved three cohorts with increasing MGD severity: no MGD, mild/moderate MGD, and severe MGD. Symptoms were assessed with an ocular symptom questionnaire grading blurred vision, eye burning, eye dryness, eye pain, light sensitivity, eye itching, eye foreign body sensation, and overall ocular discomfort. Sign assessments included the maximum meibum quality score (MMQS), tear breakup time, Schirmer tear tests, biomicroscopy, and corneal staining. Signs and symptoms were compared between cohorts and study visits. Results: Seventy-five study participants were assigned to the cohorts (25 per cohort). MMQS scores increased with increasing MGD severity, reflecting the selection criteria for the cohorts. Between-visit scores showed a weighted kappa statistic of 0.72 indicating substantial agreement. Mean scores of all assessed symptoms increased with increasing MGD severity. Scores for symptoms showed moderate (κ = 0.41-0.60) to substantial (κ = 0.61-0.80) agreement between visits. Overall ocular discomfort demonstrated the strongest correlation with the MMQS. Conclusion: The MMQS was a reproducible sign of MGD showing good agreement with ocular symptoms. Overall ocular discomfort was well correlated with typical dry eye symptoms and could potentially be used as a single measure of MGD symptoms. The findings from this observational study may inform endpoints for future clinical trials. ClinicalTrials.gov NCT01979887.

RNA Profiles of Tear Fluid Extracellular Vesicles in Patients with Dry Eye-Related Symptoms

Currently, diagnosing and stratifying dry eye disease (DED) require multiple tests, motivating interest in a single definitive test. The purpose of this study was to investigate the potential for using tear fluid extracellular vesicle (EV)-RNA in DED diagnostics. With a role in intercellular communication, nanosized EVs facilitate the protected transport of diverse bioactive molecules in biofluids, including tears. Schirmer strips were used to collect tears from 10 patients presenting with dry eye-related symptoms at the Norwegian Dry Eye Clinic. The samples comprised two groups, five from patients with a tear film break-up time (TBUT) of 2 s and five from patients with a TBUT of 10 s. Tear fluid EV-RNA was isolated using a Qiagen exoRNeasy Midi Kit, and the RNA was characterized using Affymetrix ClariomTM D microarrays. The mean signal values of the two groups were compared using a one-way ANOVA. A total of 26,639 different RNA transcripts were identified, comprising both mRNA and ncRNA subtypes. Approximately 6% of transcripts showed statistically significant differential abundance between the two groups. The mRNA sodium channel modifier 1 (SCNM1) was detected at a level 3.8 times lower, and the immature microRNA-130b was detected at a level 1.5 times higher in the group with TBUT 2 s compared to the group with TBUT 10 s. This study demonstrates the potential for using tear fluid EV-RNA in DED diagnostics.

Individuals with Diabetes Mellitus Have a Dry Eye Phenotype Driven by Low Symptom Burden and Anatomic Abnormalities

Dry eye disease is an umbrella term that includes a variety of symptoms and signs. A link between diabetes mellitus and dry eye disease exists, but the associated phenotype needs further examination. Thus, our aim was to determine how diabetes mellitus relates to the dry eye disease phenotype. A prospective, cross-sectional study was conducted at the Miami Veteran Affairs Medical Center ophthalmology clinic between October 2013 and September 2019. Participants included a volunteer sample of 366 South Florida veterans with one or more symptoms or signs of dry eye disease [Dry Eye Questionnaire-5 ≥ 6 OR tear break-up time ≤ 5 OR Schirmer's test score ≤ 5 OR corneal fluorescein staining ≥ 2]. Participants were divided into three groups: (1) individuals without diabetes mellitus (controls); (2) individuals with diabetes mellitus but without end-organ complications; and (3) individuals with diabetes mellitus and end-organ complications. Dry eye metrics were compared across groups. The main outcome measures included ocular symptom questionnaires [e.g., 5-item Dry Eye Questionnaire, Ocular Surface Disease Index, and ocular pain assessment] and clinical parameters obtained from an ocular surface evaluation. A total of 366 individuals were included (mean age 59 ± 6 years; 89% males; 39% White; 11% diabetes mellitus and end-organ complications; 15% diabetes mellitus but without end-organ complications). Individuals with diabetes mellitus and end-organ complications had lower symptom scores on the dry eye disease and pain-specific questionnaires compared to individuals with diabetes mellitus but without end-organ complications and controls (Ocular Surface Disease Index: 42.1 ± 24.5 vs. 38.9 ± 25.1 vs. 23.6 ± 16.2; p < 0.001; numerical rating scale of ocular pain intensity: 4.9 ± 3.2 vs. 4.3 ± 2.7 vs. 3.5 ± 2.7; p = 0.02). Eyelid laxity was also more severe in the group with diabetes mellitus and end-organ complications (0.69 ± 0.64 vs. 0.73 ± 0.72 vs. 1.08 ± 0.77; p = 0.004) compared to the two other groups. The diabetic dry eye disease phenotype is driven by signs more so than by symptoms, with anatomic eyelid abnormalities being more frequent in individuals with diabetes mellitus and end-organ complications. Given this, ocular surface abnormalities in individuals with DM may be missed if screened by symptoms alone. As such, individuals with DM should undergo a slit lamp examination for signs of ocular surface disease, including anatomic abnormalities.

Efficacy of Interleukin-1β Inhibitor on Dry Eye Disease in Patients with Degenerative Arthritis

Purpose

To evaluate diacerein (interleukin-1β inhibitor) efficacy on ocular surface disease (OSD).

Patients and Methods

This prospective observational study included patients who received diacerein for osteoarthritis and had dry eye (DE). The primary outcome was corneal staining score. Secondary outcomes were ocular surface disease index (OSDI) score, tear breakup time (TBUT), tear osmolarity (Osm), Schirmer's test results, interleukin-1α (IL-1α), interleukin-1β (IL-1β), and interleukin-1 receptor antagonist (IL-1Ra) levels in tears. All measurements were done at baseline and 2-month follow-up visits. Linear mixed models were used to examine the effect of all parameters, and log-transformed models were used for IL-1α, IL-1β, and IL-1Ra analyses.

Results

Thirty-four patients (31 females and 3 males) were enrolled. The corneal staining score improved by 1.29 points (P=0.022, 95% confidence interval [95% CI] 0.19 to 2.40) after 2 months, and the OSDI score improved by 17.2 points (P<0.001, 95% CI 10.82 to 23.58) but TUBT decreased by 0.66 seconds (P=0.021, 95% CI 0.10 to 1.22). No significant differences were observed in the tear Osm and Schirmer's test. IL-1Ra demonstrated no statistical difference, IL-1α was significantly increased by 80% (P=0.260), and IL-1β was significantly decreased by 99.21% (P<0.001).

Conclusion

Diacerein can improve corneal staining and decrease IL-1β levels in tears, which reflects better DE symptoms. Diacerein may be a promising alternative treatment for patients with OSD and osteoarthritis.

The Effect of Sodium Hyaluronate Eye Drops 2, 4 or 6 Times a Day on Signs and Symptoms of Dry Eye Disease

Purpose

A randomized clinical trial was run to evaluate the effectiveness of a preservative-free 0.4% sodium hyaluronate eye drop (LOF) in different dosage schemes to alleviate signs and symptoms of dry eye disease (DED).

Methods

A total of 116 subjects with mild-to-moderate DED were included, and 111 completed the study (from which 67.6% were female and 65.3% were users of oral contraceptives). Patients were randomly assigned to instill a drop of LOF either 2 (BID), 4 (QID) or 6 (6TD) times a day (at least 3 hours apart) for 30 days. The clinical parameters and symptom endpoints were Ocular Surface Disease Index (OSDI), tear break-up time (TBUT), ocular surface staining, and conjunctival hyperemia. Other parameters evaluated were chemosis, best corrected visual acuity, and the incidence of adverse events (AE).

Results

There was a significant reduction in OSDI scores by day 30 in all groups. The recovery of the OSDI score back to normal values was observed in 51.4% of patients treated (50%, 48.6%, and 55.6% in BID, QID, and 6TD, respectively, p = 0.822). Similar improvement was observed for TBUT, 50.5% of patients increased this variable to >10 seconds (39.5%, 51.4%, and 61.1%, p = 0.175), and for ocular surface staining, ≥72% showed Grade 0. There were no significant differences among posology groups regarding ocular surface staining, conjunctival hyperemia, or any safety parameters. No overall improvement in OSDI and TBUT to normal values was noted for 31 patients (21 were female and 71.4% users of contraceptive drugs).

Conclusion

The ophthalmic use of preservative free LOF, 2, 4 or 6 times a day, may alleviate clinical parameters and symptoms in 50% of patients with mild-to-moderate DED after a one-month treatment. This improvement seemed to be less ubiquitous in patients within reproductive age and using oral contraceptives.

Trial Registration

This trial is registered at clinicaltrials.gov (NCT0704531).

Influence of Vitreoretinal Surgery on Ocular Surface Dynamics Using Keratograph 5M

PURPOSE

To evaluate changes of ocular surface dynamics using Keratograph 5M for 3 months after vitreoretinal surgery.

METHODS

Eighty-three patients were divided into three groups: phacoemulsification group, vitrectomy group, and combined group. Keratograph 5M was performed for all patients at 1 week, 1 month, and 3 months after the surgery. Ocular surface dynamics parameters measured by Keratograph 5M, including noninvasive keratograph first tear film breakup time (NifBUT), noninvasive keratograph average tear film breakup time (NiaBUT), and tear meniscus height (TMH) were compared among the three groups over time.

RESULTS

The mean age of all patients (46 men and 37 women) was 62.2 ± 8.4 years. NifBUT and NiaBUT were significantly decreased at 1 week after surgery compared to those at baseline in all three groups (all p < 0.001). NifBUT and NiaBUT in the phacoemulsification group almost recovered to the preoperative level, while those in the vitrectomy group and the combined group were still significantly less than those at baseline. NifBUT and NiaBUT in the phacoemulsification group were significantly longer than those in the vitrectomy group and the combined group at 3 months. After 1 week, TMHs were significantly higher in the vitrectomy group (p = 0.001) and the combined group (p = 0.022) than in the phacoemulsification group, while TMHs were significantly less in the vitrectomy group (p = 0.010) and the combined group (p < 0.001) than in the phacoemulsification group at 3 months after surgery.

CONCLUSIONS

These results suggest that vitreoretinal surgery could induce alteration of ocular surface dynamics for 3 months. The vitrectomy group and the combined group showed tear film instability compared to the cataract surgery alone group. Patients who underwent vitreoretinal surgery experienced more severe dry eye syndrome symptoms than those who underwent cataract surgery. Thus, managing dry eye syndrome after vitreoretinal surgery should be considered important for patients.

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist

PURPOSE OF REVIEW

Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease.

RECENT FINDINGS

The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

The effects of facial mask use on ocular surface parameters and tear film cytokine profile in prolonged use

OBJECTIVE

To compare tear fluid levels of matrix metalloproteinase 9 (MMP-9) and IL-1ß cytokines between healthcare workers wearing facial masks and controls with correlations in clinical findings.

METHODS

In a prospective, controlled clinical trial tear fluid was analyzed for MMP-9 and IL-1ß levels using a commercially available test (Invitrogen; Thermo Fisher Scientific Inc. Waltham, Massachusetts, USA). Symptoms and signs of dry eye disease (DED) were evaluated using the ocular surface disease index (OSDI), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH), Oxford corneal staining, meibomiography, and clinical findings of meibomian gland dysfunction (MGD).

RESULTS

In the 38 eyes of healthcare workers and 30 eyes of controls, there was no statistically significant difference between the groups in terms of age and sex (p > 0.05). The mean OSDI score, daily mask wear time, meibomiography degree, and rate of positive clinical findings of MGD were higher in group 1 than in group 2, and the mean NIBUT was higher in group 2. (p > 0.05). The mean values of IL-1ß and MMP-9 were higher in group 1 (p = 0.036 and p = 0.001, respectively). The TMH and Oxford score percentages were similar between the two groups (p > 0.05).

CONCLUSIONS

Elevated levels of IL-1ß and MMP-9 in the basal tear fluid reveal increased ocular inflammation in healthcare professionals. Lower NIBUT values with higher OSDI and meibomian gland loss scores support ocular surface disturbance depending on regular mask use.

Spectrum of and Factors Associated with Eye Disorders among Rheumatoid Arthritis Patients Attending Tertiary Hospital in Uganda

Background

Ocular morbidities associated with rheumatoid arthritis (RA) have not received much attention in Africa, particularly in sub-Saharan Africa. They are among the commonest (40%) extra-articular organ involvement in RA. If undiagnosed, there is a potential risk of them causing visual impairment or blindness. There is no documented study in Uganda on the magnitude of eye disorders among RA patients.

Aim

To determine the spectrum of eye disorders and associated factors among patients with RA attending Mulago National Referral Hospital.

Methods

A hospital based cross-sectional study was conducted among adults with RA attending the rheumatology clinic between July 2021 and September 2021. Clinical and sociodemographic data were collected, and ophthalmologic examinations were performed on all consenting participants. Modified Poisson regression with robust standard error was used to determine factors associated with eye disorders.

Results

Overall, 105 patients with RA were enrolled, of which, 53 (50.5%) had eye disorders. The commonest disorder (54.7%, n=29) was dry-eye syndrome. Factors that were significantly associated with eye disorders were age 36-55 years (aPR 1.56, p=0.015), duration of RA >5 years (aPR 1.81, p=0.001), use of hydroxychloroquine >5 years (aPR 1.77, p=0.041), dose of oral steroids >10 mg/day (aPR 1.49, p=0.034), and history of both diabetes and hypertension (aPR 1.87, p=0.014).

Conclusion

The prevalence of eye disorders among patients with RA was high, with the commonest being dry-eye syndrome. We recommend that ocular examinations be performed on every patient at the time of RA diagnosis for early detection of eye disorders.

Ocular Pain after Refractive Surgery: Interim Analysis of Frequency and Risk Factors

PURPOSE

To examine the frequency and risk factors for ocular pain after laser assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK).

DESIGN

Prospective study of individuals undergoing refractive surgery at 2 different centers.

PARTICIPANTS

One hundred nine individuals undergoing refractive surgery: 87% LASIK and 13% PRK.

METHODS

Participants rated ocular pain on a numerical rating scale (NRS) of 0 to 10 before surgery and 1 day, 3 months, and 6 months after surgery. A clinical examination focused on ocular surface health was performed 3 and 6 months after surgery. Persistent ocular pain was defined as an NRS score of 3 or more at both 3 and 6 months after surgery (patients), and this group was compared with individuals with NRS scores of < 3 at both time points (control participants).

MAIN OUTCOME MEASURES

Individuals with persistent ocular pain after refractive surgery.

RESULTS

The 109 patients who underwent refractive surgery were followed up for 6 months after surgery. Mean age was 34 ± 8 years (range, 23-57 years); 62% self-identified as female, 81% as White, and 33% as Hispanic. Eight patients (7%) reported ocular pain (NRS score ≥ 3) before surgery, with the frequency of ocular pain increasing after surgery to 23% (n = 25) at 3 months and 24% (n = 26) at 6 months. Twelve patients (11%) reported an NRS score of 3 or more at both time points and constituted the persistent pain group. Factors that predicted persistent pain after surgery in a multivariable analysis were (1) ocular pain before surgery predicated persistent pain after surgery (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.06-3.31), (2) symptom report of depression before surgery (Patient Health Questionnaire-9: OR, 1.3; 95% CI, 1.1-1.6; P = 0.01), (3) use of an oral antiallergy medication before surgery (OR, 13.6; 95% CI, 2.1-89.3; P = 0.007), and (4) pain intensity day 1 after surgery (OR, 1.6; 95% CI, 1.2-2.2; P = 0.005). There were no significant associations between ocular surface signs of tear dysfunction and ocular pain, P > 0.05 for all ocular surface signs. Most individuals (> 90%) were completely or somewhat satisfied with their vision at 3 and 6 months.

CONCLUSIONS

Eleven percent of individuals reported persistent ocular pain after refractive surgery, with several preoperative and perioperative factors predicting pain after surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

International survey on dry eye diagnosis by experts

Purpose

To evaluate patterns and opinion from international experts with respect to dry eye disease (DED) diagnosis in clinical practice.

Methods

An online survey was distributed to worldwide DED experts. The use of diagnosis tests was evaluated including: symptoms questionnaires, functional tests, tear stability, tear volume, tear composition, surface damage and inflammation, and eyelid assessment. After the subjective importance of symptoms, tear break up time (TBUT), non-invasive TBUT, Schirmer's test, tear meniscus height, tear osmolarity, tear metalloproteinase 9, blepharitis assessment and non-contact meibography was evaluated according to likert scale.

Results

The survey was sent to 109 experts, and 77 completed the questionnaire (rate of response = 70.6%). Most of the participants were from North America (27%) and Europe (40%). A majority of respondents (73%) diagnose DED using clinical signs and symptoms, but not fulfilling a specific criteria. Seventy-six participants (98.7%) use symptoms questionnaires. All participants evaluate damage to ocular surface, and fluorescein staining is the most frequent method used (92%). Also, all the respondents perform meibomian gland and blepharitis assessment. On the other hand, only 69.8% evaluate tear composition, being osmolarity the most common test used (66.2%). Regarding to the importance of tests, TBUT (p = 0.002) and Schirmer's (p = 0.021) were found to be more important to experts from Europe than North America. No differences were found in any other test (p > 0.05).

Conclusions

This survey offers updated and day-to-day diagnostic clinical practice by DED worldwide experts. The results highlight the importance of symptoms and clinical signs, but not necessarily following a strict criteria.

Detection of Corneal Ulcer Using a Genetic Algorithm-Based Image Selection and Residual Neural Network

Corneal ulcer is one of the most devastating eye diseases causing permanent damage. There exist limited soft techniques available for detecting this disease. In recent years, deep neural networks (DNN) have significantly solved numerous classification problems. However, many samples are needed to obtain reasonable classification performance using a DNN with a huge amount of layers and weights. Since collecting a data set with a large number of samples is usually a difficult and time-consuming process, very large-scale pre-trained DNNs, such as the AlexNet, the ResNet and the DenseNet, can be adapted to classify a dataset with a small number of samples, through the utility of transfer learning techniques. Although such pre-trained DNNs produce successful results in some cases, their classification performances can be low due to many parameters, weights and the emergence of redundancy features that repeat themselves in many layers in som cases. The proposed technique removes these unnecessary features by systematically selecting images in the layers using a genetic algorithm (GA). The proposed method has been tested on ResNet on a small-scale dataset which classifies corneal ulcers. According to the results, the proposed method significantly increased the classification performance compared to the classical approaches.