n-3 Fatty Acid Supplementation for the Treatment of Dry Eye Disease

Magnitude and Predictors of the Placebo Effects in the Dry Eye Assessment and Management Study

Purpose

To determine the magnitude and predictors of placebo effects on dry eye symptoms and signs in the Dry Eye Assessment and Management (DREAM) study.

Design

Secondary analysis of data from the DREAM study, a large-scale multicenter randomized clinical trial of patients with moderate to severe dry eye disease (DED).

Participants

One hundred sixty-four participants who were randomized to the placebo group (daily oral 1000 mg refined olive oil) and completed a 12-month follow-up in 27 United States centers.

Methods

At baseline, 3, 6, and 12 months, DED symptoms were evaluated using the Ocular Surface Disease Index (OSDI), and signs were assessed using conjunctival staining, corneal staining, tear break-up time (TBUT), Schirmer test, and meibomian gland dysfunction (MGD). Placebo effects were calculated as changes from baseline in DED symptoms and signs over 12 months. Univariable and multivariable models determined predictors for placebo effects.

Main Outcome Measures

Changes from baseline in DED symptoms and signs over 12 months after administration of the placebo.

Results

Among 164 participants (mean age 58 years, 82% female, 74% White) randomized to the placebo group, there were significant placebo effects that were evident by 3 months and remained until 12 months with improvement in OSDI total score (mean decline 10.4 points, P < 0.001), conjunctival staining score (mean decrease 0.5 points, P < 0.001), corneal staining score (mean decrease 0.9 points, P < 0.001), TBUT (mean increase 0.7 seconds, P < 0.001), and MGD score (mean decrease 0.3 points, P = 0.01). In multivariable analysis, a higher baseline OSDI total score (P < 0.001) and absence of rheumatoid arthritis (P = 0.01) predicted more improvement in OSDI total score (R 2  = 0.25). More severe DED in OSDI (P = 0.005), conjunctival staining (P = 0.04), and MGD (P < 0.001) at baseline predicted more improvement in MGD score (R 2  = 0.25).

Conclusions

The DREAM study revealed significant placebo effects on DED symptoms and signs, with more severe DED predicting larger placebo effects. Future DED trials should consider placebo effects in the trial design, statistical analysis, and result interpretation.

Financial Disclosures

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Multicenter, Randomized, Clinical Trial Assessing the Effect of rTG-Omega 3 Supplementation on Meibomian Gland Dysfunction Patients after Cataract Surgery rTG-Omega 3 for Meibomian Gland Dysfunction

Background/Aims: To investigate the effectiveness of re-esterified triglyceride form of omega 3 (rTG-omega 3) on patients with meibomian gland dysfunction (MGD) after cataract surgery. Methods: This multicenter, randomized, investigator-blinded, clinical study was conducted between June 2021 and March 2023 and enrolled 107 patients with MGD who had undergone cataract surgery within 3 months at seven sites across South Korea. Patients were randomly assigned to rTG-omega 3 group or a control group. We compared (1) tear film break-up time (TBUT) (s), (2) corneal fluorescein staining score [National Eye Institute/Industry (NEI) scale], (3) conjunctival fluorescein staining score (NEI scale), (4) strip meniscometry (SM) tube score (mm), (5) MGD stage, (6) MG quality, (7) MG expressibility, (8) Standard Patient Evaluation of Eye Dryness (SPEED) score, and (9) Ocular Surface Disease Index (OSDI) scores at baseline and 6 and 12 weeks. Results: TBUT, corneal fluorescein staining score, and SM tube score were significantly improved in the rTG-omega 3 group compared with control group (P = 0.005, P = 0.003, and P = 0.0049, respectively). Subjective questionnaire responses were also improved significantly (SPEED score, P = 0.022; OSDI score, P = 0.0011). MGD parameters were not significantly different. However, during subanalysis, significant improvements in MG quality and expressibility were observed in the MGD stage 4 group with rTG-omega 3 supplementation (P = 0.0177 and P = 0.0205, respectively). Discussion: rTG-omega 3 supplementation facilitated improvements in both objective and subjective parameters. In particular, MG quality and expressibility were significantly improved in the severe MGD group.

Bayesian Solutions for Assessing Differential Effects in Biomarker Positive and Negative Subgroups

The number of clinical trials that include a binary biomarker in design and analysis has risen due to the advent of personalised medicine. This presents challenges for medical decision makers because a drug may confer a stronger effect in the biomarker positive group, and so be approved either in this subgroup alone or in the all-comer population. We develop and evaluate Bayesian methods that can be used to assess this. All our methods are based on the same statistical model for the observed data but we propose different prior specifications to express differing degrees of knowledge about the extent to which the treatment may be more effective in one subgroup than the other. We illustrate our methods using some real examples. We also show how our methodology is useful when designing trials where the size of the biomarker negative subgroup is to be determined. We conclude that our Bayesian framework is a natural tool for making decisions, for example, whether to recommend using the treatment in the biomarker negative subgroup where the treatment is less likely to be efficacious, or determining the number of biomarker positive and negative patients to include when designing a trial.

Associations of the Severity of Dry Eye Symptoms and Signs with Quality of Life in the Dry Eye Assessment and Management (DREAM) Study

Purpose: To assess associations of the severity of the symptoms and signs of dry eye disease (DED) with the quality of life in patients with moderate-to-severe DED. Methods: At baseline, 6 and 12 months, participants (n = 535) were assessed for DED symptoms using the Ocular Surface Disease Index (OSDI) and signs using conjunctival staining, corneal staining, tear break-up time (TBUT), Schirmer's testing, meibomian gland dysfunction, and tear osmolarity. Quality of life was evaluated using the Short Form Health Survey (SF-36), consisting of a Physical Component Summary (PCS) and Mental Component Summary (MCS). Spearman correlation coefficients (rho) were used to evaluate correlations between the severity of DED and the SF-36. Results: At baseline, worse DED symptoms indicated by a higher OSDI total score were correlated with worse PCS (rho = -0.13, p = 0.002) and MCS (rho = -0.09, p = 0.03) in the SF-36. Worse vision-related function was correlated with a worse PCS score (rho = -0.18, p < 0.0001), and worse ocular symptoms were correlated with a worse MCS score (rho = -0.15, p < 0.001). More severe DED signs including corneal staining (rho = -0.22, p < 0.001), Schirmer test (rho = 0.11, p = 0.01), TBUT (rho = 0.14, p < 0.001), and tear osmolarity (rho = -0.12, p = 0.02) were correlated with a worse PCS score but were not correlated with MCS score (p ≥ 0.39). ln longitudinal analysis, only the worsening of ocular symptoms was significantly correlated with the worsening of the MCS score (rho = -0.09, p = 0.04). Conclusions: In patients with moderate-to-severe DED, there were significant yet weak correlations between the severity of dry eye symptoms/signs and the physical or mental components of the SF-36. Healthcare professionals should offer patients with DED symptom relief and support for the emotional and practical challenges in their daily lives.

British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease

Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multicomponent Dietary Supplementation: Impact on Tear Secretion and Ocular Surface Inflammation in Dry Eye Syndrome Patients

Dry eye syndrome (DES) is a prevalent ocular condition characterized by tear film instability, inflammation, and discomfort, affecting millions worldwide. DES is related to oxidative stress imbalance and ocular surface inflammation, which are important factors in the development of the condition. Recent studies have demonstrated that fish oil, lutein, and zeaxanthin possess anti-inflammatory and antioxidant properties. This study investigated the efficacy of a multicomponent dietary supplement in improving tear secretion and mitigating ocular surface inflammation in patients with DES. It was an open-label intervention trial. In total, 52 participants were randomly assigned to control (n = 23) and supplement (45 mg/day eicosapentaenoic acid, 30 mg/day docosahexaenoic acid, 30 mg/day lutein, and 1.8 mg/day zeaxanthin; n = 29) groups for 12 weeks. The participants were evaluated using Schirmer's test and the ocular surface disease index (OSDI) as ocular surface parameters. Moreover, blood or tear oxidative stress, antioxidant capacities, and tear inflammatory indicators were measured at weeks 0 and 12. The results indicated a significant increase in tear secretion and a significant reduction in OSDI scores in the supplement group. Additionally, inflammatory markers, such as interleukin (IL)-6 and IL-8, significantly decreased after the intervention. However, the OSDI of the supplement group significantly improved by 6.60 points (β = -6.60, p = 0.01). These findings support the potential of targeted nutritional supplementation as a safe and effective strategy for alleviating DES symptoms, offering an alternative to conventional treatments that exclusively focus on symptom management. This study highlights the role of specific nutrients in modulating tear production and inflammation, thereby providing a foundation for dietary approaches to DES treatment. Future research should explore the long-term benefits of such interventions and their impact on overall ocular health.

Surge in Eye Drop Safety Concerns and Interest in Alternative Dry Eye Disease Therapy Following Eye Drop Recalls: A Cross-Sectional Google Trends Analysis

OBJECTIVES

Beginning in January 2023, numerous eye drops were recalled following reports of contamination. To investigate hesitancy in topical therapies for dry eye disease (DED), we analyzed trends in Internet search traffic for alternative DED therapies and eye drop safety concerns following initial recalls.

METHODS

Google Trends (GT) was used to measure the popularity of specific search terms during a given time period. The main GT output metric for gauging interest in a search term is the Search Volume Index (SVI). We collected worldwide SVI data for terms "dry eye vitamin," "are eye drops safe," "stop eye drops," "lipiflow," "ilux treatment," "dry eye mask," "dry eye warm compress," "omega-3 for dry eyes," "dry eye plugs," "dry eye humidifier," "itear," and "IPL dry eye" from April 24, 2022, to October 29, 2023. Statistical analysis was performed with Microsoft Excel v.16.77.1, and comparisons between groups were performed using paired t tests.

RESULTS

A significant increase in SVI was observed for most keywords. When comparing the 40-week period before and after the initial recall, 7/10 alternative DED therapies demonstrated a statistically significant surge in Internet search traffic after recall ( P < 0.05). Furthermore, 2/2 keywords pertaining to eye drop safety concerns demonstrated an increase in SVI ( P < 0.0001).

CONCLUSIONS

We identified a significant surge in Internet search activity for eye drop safety and alternative DED therapies following eye drop recalls. Public health agencies and physicians may find this information valuable while attempting to address safety concerns and navigating noncompliance of routine eye drop therapy.

Dry eye and systemic diseases

Tear film instability and reduced tear production initiate a vicious circle where hyperosmolarity, ocular inflammation, and apoptosis may induce a damage of the ocular surface including keratitis which is all included in a common condition called dry eye disease (DED). DED can be apparently an isolated ocular surface condition; however, multiple ocular and systemic risk factors have been identified. The association with systemic diseases such as autoimmune diseases, hormonal imbalance, dietary imbalance, metabolic diseases, infections, psychological conditions, and aging together with external causative factors may act independently or interacting each other to initiate and/or perpetuate signs and symptoms typical of this very common ocular surface disease. Rheumatological disorders are most typically associated with dry eye; therefore, strict interaction with rheumatologists is important for the diagnosis and management of DED patients. In the present narrative review, we highlight associations between DED and some of the systemic disorders that may be implicated in the development of the disease.

Mental burden of ocular surface discomfort

OBJECTIVE

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Low Expression of Vitamin D Receptor in Patients With Dry Eye Disease

PURPOSE

This study aimed to compare the expression of vitamin D receptor (VDR) on the ocular surface of patients with dry eye disease (DED) and controls without ophthalmological pathologies.

METHODS

Patients with DED without previous treatment were studied and compared with healthy subjects. Ocular Surface Disease Index assessement and ocular surface cytology were performed in all patients. The immunohistochemical expression of VDR was evaluated using fully automated immunohistochemistry. The evaluation involved multiplying the percentage of nuclear-labeled cells (0-100) by their intensity (0-3), resulting in a score ranging from 0 to 300 (VDR H-score). Squamous metaplasia was morphologically evaluated using liquid-phase cytology with Papanicolaou/periodic acid-Schiff staining using Nelson's grade (scale 0-3, higher grade to higher metaplastic change).

RESULTS

Eighteen patients with DED without previous treatment and 10 healthy subjects were studied. Squamous metaplasia was observed in 74% of patients with DED, in contrast to 0% in the control group. In patients with DED, there was a lower expression of VDR than in the control group (VDR H-score: 11.2 ± 13.9 vs. 80.9 ± 56; P = 0.0001). Furthermore, an inverse correlation was observed between Nelson grade and VDR H-score ( P = 0.0001, rs = -0.71). No correlation was observed between Ocular Surface Disease Index and VDR H-score.

CONCLUSIONS

This is the first study to evaluate the VDR in patients with DED. These patients presented with a lower expression of VDR than healthy subjects. No correlation was found with more severe symptoms. Patients with DED also had a higher frequency of squamous metaplasia.

How Eyelid Changes May Impact on Tears

This article examines the impact of eyelid margin diseases on tear film composition and associated ocular surface disorders. It highlights the prevalence of blepharitis and meibomian gland dysfunction, discussing risk factors and diagnostic considerations. Various therapeutic approaches, including eyelid hygiene, antibiotics, and innovative treatments, are explored. Emphasizing the chronic nature of these conditions, the article underscores the need for patient compliance. Overall, it provides a concise overview of eyelid-related issues and potential management strategies.

Two-Year Progression of Dry Eye Disease in Dry Eye Assessment and Management Study

PURPOSE

The purpose of this study was to evaluate the progression of dry eye disease (DED) symptoms and signs over 2 years through a secondary analysis of data collected from the Dry Eye Assessment and Management study.

METHODS

Participants who were assigned to omega-3 fatty acid in the first year were rerandomized in the second year to either continue with omega-3 fatty acid or switch to placebo. At baseline, 3, 6, 12, 18, and 24 months, DED symptoms were evaluated by using the Ocular Surface Disease Index and the Brief Ocular Discomfort Index (BODI). DED signs were assessed using conjunctival staining, corneal staining, tear break-up time, Schirmer testing, and keratography measures. Medication usage was documented at each visit. Because the treatment and placebo groups displayed no statistical differences in both signs and symptoms, data from the 43 participants were combined to assess longitudinal changes in symptoms and signs.

RESULTS

At 3 months after omega-3 fatty acid treatment, there were significant improvements from baseline in Ocular Surface Disease Index and Brief Ocular Discomfort Index scores (all P ≤ 0.002) and less use of artificial tears or gel ( P = 0.02), but between 3 and 24 months, no significant changes in symptoms and treatments were observed ( P ≥ 0.06). Except for a significant improvement in conjunctival staining score over 2 years ( P = 0.001), there were no significant sign changes in corneal staining ( P = 0.32), tear break-up time ( P = 0.43), Schirmer test ( P = 0.09), and additional measures (all P ≥ 0.07).

CONCLUSIONS

We did not observe a progression of DED signs or symptoms over a 2-year period, except for a probable placebo response in symptoms in the first 3 months and an improvement in conjunctival staining score.

Microbiome as an endocrine organ and its relationship with eye diseases: Effective factors and new targeted approaches

Microbiome is an endocrine organ that refers to both the complicated biological system of microbial species that colonize our bodies and their genomes and surroundings. Recent studies confirm the connection between the microbiome and eye diseases, which are involved in the pathogenesis of eye diseases, including age-related macular disorders, diabetic retinopathy, glaucoma, retinitis pigmentosa, dry eye, and uveitis. The aim of this review is to investigate the microbiome in relation to eye health. First, a brief introduction of the characteristics of the gut microorganisms terms of composition and work, the role of dysbiosis, the gut microbiome and the eye microbiome in the progression of eye illnesses are highlighted, then the relationship among the microbiome and the function of the immune system and eye diseases, the role of inflammation and aging and the immune system, It has been reviewed and finally, the control and treatment goals of microbiome and eye diseases, the role of food factors and supplements, biotherapy and antibiotics in relation to microbiome and eye health have been reviewed.

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.

Pioglitazone alleviates lacrimal gland impairments induced by high-fat diet by suppressing M1 polarization

A high-fat diet (HFD) contributes to the pathogenesis of various inflammatory and metabolic diseases. Previous research confirms that under HFD conditions, the extraorbital lacrimal glands (ELGs) can be impaired, with significant infiltration of pro-inflammatory macrophages (Mps). However, the relationship between HFD and Mps polarization in the ELGs remains unexplored. We first identified and validated the differential expression of PPAR-γ in murine ELGs fed ND and HFD through RNA sequencing. Tear secretion was measured using the Schirmer test. Lipid droplet deposition within the ELGs was observed through Oil Red O staining and transmission electron microscopy. Mps phenotypes were determined through quantitative RT-PCR, immunofluorescence, and flow cytometric analysis. An in vitro high-fat culture system for Mps was established using palmitic acid (PA), with supernatants collected for co-culture with lacrimal gland acinar cells. Gene expression was determined through ELISA, immunofluorescence, immunohistochemistry, quantitative RT-PCR, and Western blot analysis. Pioglitazone reduced M1-predominant infiltration induced by HFD by increasing PPAR-γ levels in ELGs, thereby alleviating lipid deposition and enhancing tear secretion. In vitro tests indicated that PPAR-γ agonist shifted Mps from M1-predominant to M2-predominant phenotype in PA-induced Mps, reducing lipid synthesis in LGACs and promoting lipid catabolism, thus alleviating lipid metabolic disorders within ELGs. Conversely, the PPAR-γ antagonist induced opposite effects. In summary, the lacrimal gland is highly sensitive to high-fat and lipid metabolic disorders. Downregulation of PPAR-γ expression in ELGs induces Mps polarization toward predominantly M1 phenotype, leading to lipid metabolic disorder and inflammatory responses via the NF-κb/ERK/JNK/P38 pathway.

Anterior Segment Optical Coherence Tomography Imaging of the Lacrimal Gland in Patients With Chronic Ocular Graft-Versus-Host Disease

PURPOSE

The purpose of this study was to explore the image characteristics of the palpebral lobe of the lacrimal gland in patients with chronic ocular graft-versus-host disease (coGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) using anterior segment optical coherence tomography (AS-OCT).

METHODS

This comparative cross-sectional study included 32 patients with coGVHD, 21 patients with severe aqueous tear deficiency dry eye, and 20 healthy control subjects. All subjects underwent an AS-OCT examination on the palpebral lobe of the lacrimal gland. The main outcomes are the number of visible gland lobules, ducts, and blood vessels and the proportions of mille crêpe-like structures in the AS-OCT images.

RESULTS

Compared with the other 2 groups, patients with coGVHD had significantly more blood vessels and slightly less visible lobules and ducts (all P <0.05) in the palpebral lacrimal gland. Mille crêpe-like structures were observed only in the coGVHD group. Number of blood vessels was positively correlated with time after allo-HSCT (β: 0.14, 95% confidence interval [CI], 0.01-0.26). Mille crêpe-like structure was positively correlated with coGVHD severity (odds ratio: 9.07, 95% CI, 1.75-16.38) and time after allo-HSCT (odds ratio: 0.13, 95% CI, 0.03-0.23).

CONCLUSIONS

We reported the AS-OCT characteristics of the palpebral lacrimal gland in coGVHD and found an increased number of blood vessels and mille crêpe-like structures. AS-OCT has the potential in the disease monitoring of coGVHD.

Associations of Severity of Dry Eye Symptoms and Signs with the Quality of Life in the Dry Eye Assessment and Management (DREAM) Study

Purpose: To assess associations of dry eye disease (DED) severity of symptoms and signs with the quality of life in patients with moderate-to-severe DED. Methods: At baseline, 6 and 12 months, participants (N=535) were assessed for DED symptoms using Ocular Surface Disease Index (OSDI) and signs using conjunctival staining, corneal staining, tear break-up time (TBUT), Schirmer's testing, meibomian gland dysfunction, and tear osmolarity. Quality of life was evaluated using the Short Form Health Survey (SF-36), consisting of Physical Component Summary (PCS) and Mental Component Summary (MCS). Spearman correlation coefficients (rho) were used to evaluate correlations between the severity of DED and SF-36. Results: At baseline, Worse DED symptoms indicated by higher OSDI total score were correlated with worse PCS (rho=-0.13, P=0.002) and MCS (rho=-0.09, P=0.03) of SF-36. The worse vision-related function was correlated with a worse PCS score (rho=-0.18, P<0.0001), and worse ocular symptoms were correlated with a worse MCS score (rho=-0.15, P<0.001). More severe DED signs including corneal staining (rho=-0.22, P<0.001), Schirmer test (rho=0.11, P=0.01), TBUT (rho=0.14, P<0.001), and tear osmolarity (rho=-0.12, P=0.02) were correlated with worse PCS score but were not correlated with MCS score (P≥0.39). ln longitudinal analysis, only worsening of ocular symptoms was significantly correlated with worsening of MCS score (rho=-0.09, P=0.04). Conclusion: In patients with moderate-to-severe DED, there were significant yet weak correlations between dry eye severity of symptoms/signs and physical or mental components of SF-36. Healthcare professionals should offer DED symptom relief and support for the emotional and practical challenges in their daily lives.

Eyelid margin disease (blepharitis and meibomian gland dysfunction): clinical review of evidence-based and emerging treatments

Blepharitis is a common ophthalmic condition with multiple etiologies and no definitive, universal treatment. The treatment modalities for managing lid margin diseases vary depending on the disease's cause, location, and severity. For anterior blepharitis, management options include eyelid hygiene with warm compresses, eyelid scrubs, baby shampoo, and over-the-counter eyelid cleansers. Topical antibiotics and antibiotic-steroid combination drops/ointments for the eye and eyelid may accompany these. For posterior blepharitis/meibomian gland dysfunction (MGD), at-home warm compress or in-office administration of heat therapy/thermal pulsation treatment that aims to clear obstruction in the meibomian glands and restore meibum secretions to maintain a healthy tear film is recommended. In addition to the above treatment strategies, various other compounds to manage lid margin diseases are in the late stages of development. This review summarizes the available treatment modalities or those in the pipeline for treating blepharitis and MGD.

Re-Esterified Triglyceride ω-3 Fatty Acids in Dry Eye Disease With Meibomian Gland Dysfunction: A Randomized Clinical Trial

Importance

Taking ω-3 supplements has been associated with a reduction in symptoms of dry eye disease (DED) associated with meibomian gland dysfunction (MGD). However, a recent relatively large clinical trial concluded that treating DED with ω-3 consumption was ineffective, potentially warranting additional investigations.

Objectives

To investigate the effect of re-esterified triglyceride (rTG) ω-3 fatty acid supplementation on DED associated with MGD.

Design, Setting, and Participants

This double-masked, parallel-group, randomized clinical trial was conducted at 7 institutions from September 2020 to January 2023. Patients with DED associated with MGD were included and randomly assigned to the ω-3 group (received 1680 mg of eicosapentaenoic acid and 560 mg of docosahexaenoic acid), whereas those in the grape-seed group received 3000 mg of grape-seed oil daily.

Interventions

rTG ω-3 Fatty acid supplementation vs grape-seed oil.

Main Outcome Measures

The primary end point was the Ocular Surface Disease Index (OSDI) from baseline to 6 and 12 weeks. The safety parameters were visual acuity and intraocular pressure change.

Results

A total of 132 patients (mean [SD] age, 50.6 [13.8] years; 103 female [78.0%]) were included in this study. The mean (SD) baseline OSDI scores of the ω-3 and grape-seed groups were 43.5 (16.5) and 44.1 (16.6), respectively. A total of 58 patients (87.9%) and 57 patients (86.4%) in the ω-3 and grape-seed groups, respectively, completed 12 weeks of follow-up. There were no differences in compliance with the dietary supplement intake between groups (ω-3, 95.8% and grape-seed, 95.4%). The OSDI (SD) change from baseline to 6 and 12 weeks was -20.5 (16.0) and -22.7 (15.7), respectively, in the ω-3 group and -15.1 (20.2) and -18.8 (21.7), respectively, in the grape-seed control group (difference at 6 weeks = -5.4; 95% CI, -12.15 to 1.33; P = .12 and at 12 weeks = -3.9; 95% CI, -10.90 to 3.13; P = .28). There were no changes in safety parameters or adverse events related to taking the dietary supplement in either group.

Conclusions and Relevance

This randomized clinical trial did not show a benefit of the rTG form of ω-3 for ameliorating symptoms of DED associated with MGD, although fewer than 60 participants were evaluated in each group. Any secondary outcomes from this study should be considered for hypothesis generation of future evaluations of the effect of the rTG form of ω-3 on DED associated with MGD.

Trial Registration

CRIS Identifier: KCT0004927.

Omega-3 world map: 2024 update

In 2016, the first worldwide n3 PUFA status map was published using the Omega-3 Index (O3I) as standard biomarker. The O3I is defined as the percentage of EPA + DHA in red blood cell (RBC) membrane FAs. The purpose of the present study was to update the 2016 map with new data. In order to be included, studies had to report O3I and/or blood EPA + DHA levels in metrics convertible into an estimated O3I, in samples drawn after 1999. To convert the non-RBC-based EPA + DHA metrics into RBC we used newly developed equations. Baseline data from clinical trials and observational studies were acceptable. A literature search identified 328 studies meeting inclusion criteria encompassing 342,864 subjects from 48 countries/regions. Weighted mean country O3I levels were categorized into very low ≤4%, low >4-6%, moderate >6-8%, and desirable >8%. We found that the O3I in most countries was low to very low. Notable differences between the current and 2016 map were 1) USA, Canada, Italy, Turkey, UK, Ireland and Greece (moving from the very low to low category); 2) France, Spain and New Zealand (low to moderate); and 3) Finland and Iceland (moderate to desirable). Countries such as Iran, Egypt, and India exhibited particularly poor O3I levels.

Association of Dry Eye Symptoms and Signs in Patients with Dry Eye Disease

PURPOSE

To determine the correlations among symptoms and signs of dry eye disease (DED) in the Dry Eye Assessment and Management (DREAM) study.

METHODS

A total of 535 patients with moderate-to-severe DED were assessed for symptoms using the Ocular Surface Disease Index (OSDI) and four DED signs in both eyes (conjunctival lissamine green staining, corneal fluorescein staining, Schirmer's testing, and tear break-up time (TBUT)) following standardized protocols at baseline and follow-up visits (months 3, 6, and 12). Spearman correlation coefficients (rho) were calculated for correlations among symptoms and signs of DED at baseline and among changes in symptoms and signs from baseline at 12 months. The confidence intervals and p-values for correlation coefficients were calculated using a cluster bootstrapping to account for inter-eye correlation.

RESULTS

At baseline, OSDI total score was not correlated with signs; however, OSDI subscale score of ocular symptoms was weakly correlated with corneal staining score (rho = 0.14, p = .002) and Schirmer test score (rho = 0.11, p = .01). There were statistically significant correlations among the four signs (p < .001), with absolute correlation coefficient ranging from 0.14 (conjunctival staining score vs. TBUT) to 0.33 (conjunctival staining score vs. cornea staining score). The correlations among changes in symptoms and signs were weaker, with the highest correlation between change in conjunctival staining and corneal staining (rho = 0.21, p < .001).

CONCLUSIONS

Consistent with previous studies, among DREAM participants with moderate-to-severe DED at baseline, correlations of DED symptoms with signs were low and correlations among four objective signs were low to moderate. The correlations among changes in symptoms and signs were even weaker.

Association of Systemic Markers of Inflammation with Signs and Symptoms of Dry Eye Disease and Sjogren's Syndrome in the Dry Eye Assessment and Management (DREAM©) Study

PURPOSE

To evaluate the possible role of systemic inflammation in dry eye disease (DED) via systemic inflammatory marker associations with DED signs and symptoms, and an analysis of a subgroup with Sjogren's Syndrome (SS).

METHODS

Participant serums were analyzed using line immunoassays (LIAs) for the presence of antibodies against 34 systemic inflammatory markers. Using the 2012 American College of Rheumatology definition, the 481 participants were categorized into group 1 (SS; n = 52), group 2 (autoimmune disease not including SS; n = 66), or group 3 (control, i.e. no autoimmune disease; n = 363).

RESULTS

3 markers were positive in ≥10% of participants: Ro52 (19.3%), Scl-70 (15.0%), CN-1A (14.2%). 2 markers were positively associated with symptoms: PM-Scl100 (p = 0.02), Sm (p = 0.009). 5 markers were positively associated with signs: U2SnRNP A', Ro52, La, DNA, Ro60. SS participants showed significantly higher positivity for 4 markers compared to participants with no autoimmune disease: PL-7 (p = 0.02), Ro52 (p < 0.0001), La (p < 0.0001), Ro60 (p < 0.0001). SS participants showed significantly higher positivity for 3 markers compared to participants with another autoimmune disease: Ro52 (p < 0.0001), La (p = 0.002), Ro60 (p < 0.0001).

CONCLUSIONS

This study did not show evidence of significant systemic inflammation in participants with moderate-to-severe DED, based on the markers tested. PM-Scl100 and Sm may be associated with more severe DED symptoms. U2SnRNP A', Ro52, La, DNA, and Ro60 may be associated with more severe ocular surface disease. Ro52 and PL-7 may be diagnostic markers for SS. Future research evaluating these relationships and their clinical significance is needed.

Recommendations for nutritional supplements for dry eye disease: current advances

Dry eye disease (DED) represents a prevalent ocular surface disease. The development of effective nutritional management strategies for DED is crucial due to its association with various factors such as inflammation, oxidative stress, deficiencies in polyunsaturated fatty acids (PUFAs), imbalanced PUFA ratios, and vitamin insufficiencies. Extensive research has explored the impact of oral nutritional supplements, varying in composition and dosage, on the symptoms of DED. The main components of these supplements include fish oils (Omega-3 fatty acids), vitamins, trace elements, and phytochemical extracts. Beyond these well-known nutrients, it is necessary to explore whether novel nutrients might contribute to more effective DED management. This review provides a comprehensive update on the therapeutic potential of nutrients and presents new perspectives for combination supplements in DED treatment.

A cross-sectional study of optometrists' attitudes towards dry eye disease management in Hong Kong: A web-based survey in Hong Kong

Purpose

This study aimed to explore the practices of optometrists in Hong Kong towards diagnosing and managing dry eye disease (DED).

Methods

From September 2021 to March 2022, an online questionnaire was distributed to optometrists in Hong Kong through several professional associations. The questionnaire included questions about the importance and usefulness of various diagnostic tests, as well as inquiries about management strategies and recommended follow-up schedules for DED. Responses were compared between optometrists who were more or less proactive in continuing education to identify potential differences.

Results

The analysis included 68 valid responses. Sixty-one of them were Part 1 optometrists that represents 5.5 % of registered Part 1 optometrists back in 2022. Assessment of clinical symptoms was the most commonly performed investigation (93 %) and considered the most important (75 %) procedure in DED assessments, followed by corneal staining and fluorescein tear break-up time. Traditional diagnostic tests were preferred over newer methods, such as osmolarity, which were not yet commonly used. Unpreserved lubricants (90 %) and lid hygiene (63 %) were the primary treatments recommended for mild DED. Optometrists who had more experience and frequent participation in continuing education were more confident in diagnosing and managing DED, and more likely to recommend omega-3 supplements for moderate DED.

Conclusion

The diagnostic and management strategies of optometrists in Hong Kong were generally consistent with the recommendations of the Dry Eye Workshop II report. However, standardized DED questionnaires and newer diagnostic tools were not commonly used. Evidence-based optometric care for dry eye management should be encouraged in Hong Kong optometric practice.

ω-3 Polyunsaturated Fatty Acid Status Testing in Humans: A Narrative Review of Commercially Available Options

There is an increasing body of evidence supporting a link between low intakes of ω-3 long-chain polyunsaturated fatty acids (LCPUFA) and numerous diseases and health conditions. However, few people are achieving the levels of fish/seafood or eicosapentaenoic acid and docosahexaenoic acid intake recommended in national and international guidelines. Knowledge of a person's ω-3 LCPUFA status will benefit the interpretation of research results and could be expected to lead to an increased effort to increase intake. Dietary intake survey methods are often used as a surrogate for measuring ω-3 PUFA tissue status and its impact on health and functional outcomes. However, because individuals vary widely in their ability to digest and absorb ω-3 PUFA, analytical testing of biological samples is desirable to accurately evaluate ω-3 PUFA status. Adipose tissue is the reference biospecimen for measuring tissue fatty acids, but less-invasive methods, such as measurements in whole blood or its components (e.g., plasma, serum, red blood cell membranes) or breast milk are often used. Numerous commercial laboratories provide fatty acid testing of blood and breast milk samples by different methods and present their results in a variety of reports such as a full fatty acid profile, ω-3 and ω-6 fatty acid profiles, fatty acid ratios, as well as the Omega-3 Index, the Holman Omega-3 Test, OmegaScore, and OmegaCheck, among others. This narrative review provides information about the different ways to measure ω-3 LCPUFA status (including both dietary assessments and selected commercially available analytical tests of blood and breast milk samples) and discusses evidence linking increased ω-3 LCPUFA intake or status to improved health, focusing on cardiovascular, neurological, pregnancy, and eye health, in support of recommendations to increase ω-3 LCPUFA intake and testing.

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.

A novel multi-ingredient supplement significantly improves ocular symptom severity and tear production in patients with dry eye disease: results from a randomized, placebo-controlled clinical trial

Introduction

Dry eye disease (DED) is multifactorial and characterized by a loss of tear film homeostasis that causes a cycle of tear film instability, tear hyperosmolarity, and inflammation. While artificial tears are the traditional mainstay of treatment, addressing the underlying pathophysiology could relieve symptoms and prevent progression. Increasing evidence indicates a role for oral nutritional supplementation in multiple ophthalmic diseases, including DED. Lutein, zeaxanthin, curcumin, and vitamin D3 have demonstrated protective and anti-inflammatory properties in ocular models. This prospective, randomized, double-blind, parallel, placebo-controlled study evaluated the efficacy and safety of a proprietary blend of lutein, zeaxanthin isomers, curcumin, and vitamin D3 (LCD) as a daily supplement in adult participants with DED.

Methods

Participants were randomized to receive one LCD supplement capsule (lutein 20 mg, zeaxanthin isomers 4 mg, curcumin 200 mg curcuminoids, and vitamin D3 600 IU) or placebo per day for 8 weeks (LCD, n=77; placebo, n=78). Primary outcomes were changes in tear volume (Schirmer's test) and ocular symptoms (Ocular Surface Disease Index [OSDI]).

Results

The study met its primary endpoints: the LCD group demonstrated significantly better Schirmer's test scores and improvement in overall OSDI score, versus placebo, at Day 56 (p<0.001 for both). Scores for total OSDI, and symptoms and vision domains, significantly improved by Day 14 for LCD versus placebo, (p<0.05 for all) and were maintained to Day 56 (p<0.001). In addition, the LCD group demonstrated significantly improved tear film break-up time (TBUT) and tear film osmolarity, versus placebo, by Day 56 (p<0.001), along with significant improvements in corneal and conjunctival staining (p<0.001 for both), and inflammation (matrix metalloproteinase-9; p<0.001 for each eye). Total Standard Patient Evaluation of Eye Dryness (SPEED) score, and scores for the frequency and severity domains, were significantly improved by Day 14 for LCD versus placebo (p<0.05 for all) and maintained to Day 56 (p<0.001). There was no difference between groups for artificial tear usage. The supplement was well-tolerated.

Discussion

Once-daily LCD supplementation significantly improved tear production, stability and quality, reduced ocular surface damage and inflammation, and improved participants' symptoms. LCD supplementation could offer a useful adjunct to artificial tears for patients with DED (NCT05481450).

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.

Role of Polyunsaturated Fatty Acids (PUFAs) and Eicosanoids on Dry Eye Symptoms and Signs

Polyunsaturated fatty acids (PUFAs) generate pro- and anti-inflammatory eicosanoids via three different metabolic pathways. This study profiled tear PUFAs and their metabolites and examined the relationships with dry eye (DE) and meibomian gland dysfunction (MGD) symptoms and signs. A total of 40 individuals with normal eyelids and corneal anatomies were prospectively recruited. The symptoms and signs of DE and MGD were assessed, and tear samples (from the right eye) were analyzed by mass spectrometry. Mann-Whitney U tests assessed differences between medians; Spearman tests assessed correlations between continuous variables; and linear regression models assessed the impact of potential confounders. The median age was 63 years; 95% were male; 30% were White; and 85% were non-Hispanic. The symptoms of DE/MGD were not correlated with tear PUFAs and eicosanoids. DE signs (i.e., tear break-up time (TBUT) and Schirmer's) negatively correlated with anti-inflammatory eicosanoids (11,12-dihydroxyeicosatrienoic acid (11,12 DHET) and 14,15-dihydroxyicosatrienoic acid (14,15, DHET)). Corneal staining positively correlated with the anti-inflammatory PUFA, docosahexaenoic acid (DHA). MGD signs significantly associated with the pro-inflammatory eicosanoid 15-hydroxyeicosatetranoic acid (15-HETE) and DHA. Several relationships remained significant when potential confounders were considered. DE/MGD signs relate more to tear PUFAs and eicosanoids than symptoms. Understanding the impact of PUFA-related metabolic pathways in DE/MGD may provide targets for new therapeutic interventions.

Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs

In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.

A latent profile analysis of tear cytokines and their association with severity of dry eye disease in the Dry Eye Assessment and Management (DREAM) study

This study is to identify subgroups of DED patients with different tear cytokine profiles and compare their DED symptoms and signs among subgroups. Baseline tear cytokines (IL-1β, IL-6, IL-8, IL-10, IL-17A, IFN-γ and TNF-α) were measured using a magnetic bead assay. DED symptoms were assessed by Ocular Surface Disease Index (OSDI) and signs were assessed by corneal and conjunctival staining, tear break-up time (TBUT), Schirmer's test, tear osmolarity and meibomian gland dysfunction (MGD). Latent profile analysis was performed to identify subgroups, and their scores of DED symptoms and signs were compared using generalized linear regression. Among 131 patients with total tear volume > 4 µl from both eyes, subgroup 1 (n = 23) significantly higher in IL-6 and IL-8 (all p < 0.001) and subgroup 2 (n = 108) significantly higher in IL-10 (p = 0.03), IL-17A (p < 0.001), and IFN-γ (p < 0.001). Both subgroups were similar in demographics and DED symptoms, but subgroup 1 had significantly more severe DED signs: higher conjunctival staining (3.38 vs. 2.69, p = 0.04), corneal staining (4.26 vs. 3.03, p = 0.03), lower Schirmer's test score (8.20 vs. 13.72, p < 0.001), and higher composite severity score of DED sign (0.62 vs. 0.45, p = 0.002). We identified two DED subgroups with different profiles of tear cytokines. Patients in these subgroups differed significantly in DED signs, supporting the inflammation's role in DED development and progression.

Association of Tear Cytokine Ratios with Symptoms and Signs of Dry Eye Disease: Biomarker Data from the Dry Eye Assessment and Management Study

PURPOSE

To assess the relationship between tear inflammatory cytokine ratios (CRs) and signs and symptoms of dry eye disease (DED) to investigate the possible use of tear CRs, which may better address the complexity of cytokine interactions than absolute cytokine levels, as a DED biomarker.

METHODS

Tear concentrations of IL-1b, IL-6, IL-8, IL-10, IL-17A, IFN-g, and TNF-a were measured using standardized procedures, as were DED signs (corneal and conjunctival staining scores, tear break-up time, Schirmer test, Meibomian gland plugging, tear osmolarity, composite sign severity score) and symptoms [Ocular Surface Disease Index (OSDI)]. Ratios between pro-inflammatory (IL-1b, IL-8, IL-17A, IFN-g, and TNF-a) and anti-inflammatory (IL-10) cytokines were calculated. Given its opposing roles in inflammation, IL-6 was tested as both a pro- and anti-inflammatory cytokine. Correlations between CR and DED symptoms and signs were calculated using Spearman correlation coefficients (rho).

RESULTS

At baseline, 131 patients, 80.2% female and mean age 54.2 years (SD 14.1, range 20-82), from 10 sites of the Dry Eye Assessment and Management study had sufficient tear volumes ≥4 μL for analysis. IL-6:IL-10, IL-8:IL-10, and TNF-a:IL-10 had some significant correlations, mostly with conjunctival or corneal staining or the composite sign severity score (IL-8:IL-10 and conjunctival staining: rho = 0.19, p = 0.03; IL-6:IL-10 and corneal staining: rho = 0.31, p < 0.001; IL-8:IL-10 and corneal staining: rho = 0.21, p = 0.01; IL-6:IL-10 and composite sign severity score: rho = 0.26, p = 0.003; IL-8:IL-10 and composite sign severity score: rho = 0.26, p = 0.003; TNF-a:IL-10 and corneal staining: rho = 0.29, p < 0.001; TNF-a:IL-10 and Schirmer test: rho = -0.23, p = 0.009). CRs had no significant correlation with DED symptoms. All significant correlations using IL-6 in the denominator (anti-inflammatory) produced counterintuitive results based on clinical understanding of the disease.

CONCLUSIONS

Pro- to anti-inflammatory CR was weakly correlated with some DED signs and not with symptoms, as measured by OSDI. Future studies in different dry eye populations are needed and should address sampling biases and tear collection techniques.

Interventions for Dry Eye: An Overview of Systematic Reviews

Importance

Dry eye is a common ocular disease that can have substantial morbidity. Systematic reviews provide evidence for dry eye interventions and can be useful for patients, clinicians, and clinical guideline developers. Overviews of reviews use explicit and systematic methods to synthesize findings from multiple systematic reviews, but currently, there are no overviews of systematic reviews investigating interventions for dry eye.

Objective

To summarize the results of reliable systematic reviews of dry eye interventions and to highlight the evidence gaps identified.

Evidence Review

We searched the Cochrane Eyes and Vision US satellite database and included reliable systematic reviews evaluating dry eye interventions published from 2016 to 2022. We reported the proportion of systematic reviews that were reliable with reasons for unreliability. Critical and important outcomes from reliable systematic reviews were extracted and verified. Critical outcomes included dry eye-related patient-reported outcome measures. Results were synthesized from reliable systematic reviews to provide summaries of evidence for each intervention. Evidence for each intervention was defined as conclusive or inconclusive depending on whether high-certainty evidence across systematic reviews was available according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and whether findings reached statistical or clinical significance. Recommendations were made for further research.

Findings

Within the Cochrane Eyes and Vision US satellite database, 138 potentially relevant systematic reviews were identified, 71 were considered eligible, and 26 (37%) were assessed as reliable. Among reliable systematic reviews, no conclusive evidence was identified for any dry eye intervention. Inconclusive evidence suggested that environmental modifications, dietary modifications, artificial tears and lubricants, punctal occlusion, intense pulsed light therapy, vectored thermal pulsation therapy (Lipiflow), topical corticosteroids, topical cyclosporine A, topical secretagogues, and autologous serum may be effective. Only unreliable systematic reviews evaluated lifitegrast, oral antibiotics, and moisture chamber devices.

Conclusions and Relevance

This overview of systematic reviews found some evidence that dry eye interventions may be effective, but no conclusive evidence was available. The conduct and reporting of most systematic reviews for dry eye interventions warrant improvement, and reliable systematic reviews are needed to evaluate lifitegrast, oral antibiotics, and moisture chamber devices.

Sex-related differences and hormonal effects in the Dry Eye Assessment and Management (DREAM) study

BACKGROUND/AIMS

To compare dry eye disease (DED) signs and symptoms between men and women, as well as between premenopausal and postmenopausal women, in the Dry Eye Assessment and Management (DREAM) study.

METHODS

434 women and 101 men self-reported prior medical history and underwent a standardised DED assessment using the Ocular Surface Disease Index, Brief Pain Inventory, Tear Break-Up Time (TBUT)(s), Schirmer's test 2 (mm/5 min), National Eye Institute-graded lissamine conjunctival staining, corneal staining, meibomian gland dysfunction evaluation and tear osmolarity (mOsms/L) at baseline, 6 months and 12 months. Multivariable linear regression models were used to compare these scores.

RESULTS

Women experienced significantly worse DED signs than men with lower Schirmer's test scores (9.27 vs 12.16; p<0.001), higher corneal staining scores (3.59 vs 2.70; p=0.006) and worse composite DED sign scores (0.52 vs 0.40; p<0.001). Postmenopausal women experienced significantly worse DED signs than premenopausal women with higher corneal staining scores (3.74 vs 2.58, p<0.001), higher conjunctival staining scores (2.80 vs 2.22, p<0.001), higher tear osmolarity (304 vs 299, p=0.004), lower TBUT (3.37 vs 3.93, p=0.047), worse meibomian gland dysfunction (3.05 vs 2.62, p=0.04) and worse composite DED sign scores (0.54 vs 0.42, p<0.001). There were no significant differences in DED symptoms between sex and between premenopausal and postmenopausal women (all p≥0.08).

CONCLUSION

In the DREAM study, women experienced more severe DED signs than men. Further, postmenopausal women presented with more severe DED signs than premenopausal women. Elucidating these differences may improve DED diagnosis and provide future direction in understanding sex-related differences in DED.

TRIAL REGISTRATION NUMBER

NCT02128763.

Update on Dry Eye Disease Treatment: Evidence From Randomized Controlled Trials

ABSTRACT

Although the ultimate goal of dry eye disease (DED) management is to restore the ocular surface and tear film homeostasis and address any accompanying symptoms, addressing this is not an easy task. Despite the wide range of current treatment modalities targeting multiple aspects of DED, the available DED management literature is quite heterogeneous, rendering evaluation or comparison of treatment outcomes hard or almost impossible. There is still a shortage of well-designed, large-scale, nonsponsored, randomized, controlled trials (RCTs) evaluating long-term safety and efficacy of many targeted therapies individually or used in combination, in the treatment of identified subgroups of patients with DED. This review focuses on the treatment modalities in DED management and aims to reveal the current evidence available as deduced from the outcomes of RCTs.

Efficacy of Omega-3 Intake in Managing Dry Eye Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To explore the efficacy of omega-3 fatty acids (FAs) on patients suffering from dry eye disease (DED), a complex inflammatory condition, we reviewed data from PubMed, Embase, ClinicalTrials.gov, Web of Science, and Cochrane CENTRAL in the past 10 years (2013 to 2023). These sources provided randomized clinical trials (RCTs) that examined the efficacy of omega-3 FAs on DED patients with accessible pre- and post-intervention data, excluding trials with overlapping participants, without omega-3 supplementation, or those lacking placebo control or quantitative assessments. Two independent reviewers extracted data related to dry eye symptom scores, tear break-up time (TBUT), Schirmer's tests, osmolarity, and corneal fluorescein staining (CFS), and the results were analyzed by Comprehensive Meta-Analysis software version 4. We incorporated 19 related RCTs assessed by the Cochrane Risk of Bias tool, encompassing 4246 DED patients with various etiologies. Patients given omega-3 treatment demonstrated more significant improvements in dry eye symptoms (Hedges' g = -1.047; p < 0.001), TBUT [standardized mean difference (SMD) = -0.939; p < 0.001], scores from the Schirmer test (SMD = -0.372; p < 0.001), CFS (SMD = -0.299; p = 0.037), and osmolarity (SMD = -0.721; p < 0.001) compared to those on a placebo regimen. In the meta-regression analysis of DED symptoms, the daily dose of omega-3 (coefficient = -0.0005, p = 0.002), duration of omega-3 intake (coefficient = -0.1399, p = 0.021), and percentage of eicosapentaenoic acid (EPA) (coefficient = -0.0154, p < 0.001) exhibited a significant positive correlation with a reduction in dry eye symptom scores. Apart from CFS, similar trends were noted in TBUT, Schirmer tests, and osmolarity scores. Based on the evidence, omega-3 FAs effectively reduce DED symptoms, especially in high doses, for a long duration, and with increased EPA levels. However, given the heterogeneity in study results and diverse patient characteristics, caution is needed in generalizing these findings. In conclusion, omega-3 FA supplementation is still recommended for DED management in clinical settings.

Treatment of Dry Eye Disease (DED) in Asia: Strategies for Short Tear Film Breakup Time-Type DED

Dry eye disease (DED) is a multifactorial disorder in which tear fluid homeostasis is lost, resulting in increased tear film osmolarity and ocular surface irritation. In Asia, the short tear film breakup time-type DED, which has become a global problem in recent years, is common. While the mainstay of DED treatment in the West is the suppression of inflammation, the first goal of treatment is the stabilization of the tear film in Asia. To date, artificial tears and steroid eye drops have been the main treatment for DED. However, artificial tears require frequent administration of eye drops and thus pose adherence problems, while steroids have problems with side-effects (cataracts, increased intraocular pressure). This review evaluates the new generation therapies in Asia based on what is known about them and demonstrates that they are more effective for DED than traditional therapies such as artificial tears and steroids. Based on considerations, it is proposed that the optimal treatment for the short tear film breakup time-type DED is the initial application of mucin-secretion-enhancing eye drops (long-acting diquafosol) and oral supplements; and if additional treatment is needed, cyclosporine eye drops and the adjunctive therapies presented in this review are added.

Real Life Impact of Dry Eye Disease

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

Patient-Reported Outcome Measure Use in Guidelines Published by the American Academy of Ophthalmology: A Review

TOPIC

We reviewed the use of patient-reported outcome measures (PROMs) in the treatment of ophthalmologic conditions as recommended by the Clinical Practice Guidelines (CPGs) published by the American Academy of Ophthalmology (AAO).

CLINICAL RELEVANCE

Patient-reported outcome measures are standardized instruments that provide information regarding a patient's health status or health-related quality of life. Patient-reported outcome measures are increasingly used to inform study end points in ophthalmology studies. However, the extent to which PROMs are ultimately informing patient management recommendations in ophthalmology as part of CPGs remains an area of evidence gap.

METHODS

We included all CPGs published by the AAO from inception to June 2022. We also included all primary studies and systematic reviews cited in the treatment sections of the CPGs evaluating treatment of an ophthalmic condition. The primary outcome was the frequency of PROMs discussed in CPGs and in cited studies evaluating treatment. Secondary outcomes included frequency of minimal important difference (MID) use to contextualize PROM results and percentage of strong and discretionary recommendations supported by PROMs. We published a study protocol a priori on PROSPERO (CRD42022307427). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We assessed risk of bias using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

RESULTS

We identified 24 eligible CPGs, providing 2458 cited studies (2191 primary, 267 secondary) evaluating treatment of eye conditions. Ten CPGs (41.7%) reported consideration of PROMs. Of these, 31 of 94 (33%) recommendations were informed by studies evaluating a PROM as an outcome. Across all studies cited in the development of CPGs, 221 (9.0%) used PROMs as a primary or secondary outcome, of which 4 PROM results (1.8%) were interpreted using an empirically determined MID. Overall, the risk of bias was low for all CPGs.

CONCLUSIONS

Overall, outcomes of PROMs are seldom used in ophthalmology CPGs published by the AAO and in cited primary and secondary research on treatments. When PROMs were considered, their interpretation was seldom based on an MID. To improve patient care, guideline developers may consider incorporating PROMs and applicable MIDs to inform key outcomes when formulating treatment recommendations.

FINANCIAL DISCLOSURE(S)

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

Outcomes of the addition of oral administration of curcumin-phospholipid to hyaluronic acid-based tear substitute for the treatment of dry eye disease

The aim of this study is to report the clinical outcomes of oral supplementation with curcumin-phospholipid in addition to hyaluronic acid-based tear substitute for the management of dry eye disease (DED). Patients with a diagnosis of DED confirmed by pathological values of both NIKBUT <10 s. and OSDI Questionnaire score > 12 were included. Patients were randomized to receive 2 different treatments: 0.25% hyaluronic acid-based tear substitute 3 time daily (Group 1) or as above plus curcumin-phosphatidylcholine complex tablets once a day (Group 2). Patients were evaluated at baseline (T0) and after 90 days of treatment (T1) by means of Keratograph for the measurement of NIKBUT, TMH, meibomian gland dropout and bulbar redness. Overall, data from 90 eyes of 45 patients were included. Group 1 consisted of 48 eyes of 24 patients, while group 2 included 42 eyes of 21 patients. When comparing median values of both groups at T0, no statistically significant differences were found for all parameters; instead for T1, statistically significant differences were found for redness and OSDI compared to Group 1. In group 1, a statistically significant reduction after the treatment was detected for Nikbut average and OSDI questionnaire; while in group 2, a statistically significant reduction after treatment was recorded for Nikbut average, bulbar redness and OSDI questionnaire. The addition of an oral supplement containing curcumin-phospholipid may help in a greater improvement of bulbar redness and subjective ocular symptoms compared to the treatment with tear substitutes alone for the management of DED.

Greater adherence to a mediterranean diet is associated with lower C-reactive protein (CRP) levels, but not to lower odds of having dry eye disease

PURPOSE

To investigate the hypothesis that a Mediterranean diet is associated with a lower risk of having dry eye disease (DED) in the general population.

METHODS

DED was assessed using the Women's Health Study (WHS) dry eye questionnaire in 58,993 participants from the Dutch Lifelines Cohort with complete available dietary data (20-94 years, 60% female). Level of adherence to a traditional Mediterranean diet was assessed using the modified Mediterranean Diet Score (mMDS). High-sensitivity C-reactive Protein (hsCRP) was included as a marker of whole-body inflammation. Logistic regressions were used to examine the relationship between WHS-defined DED and mMDS, corrected for age, sex, BMI, education, income, and 48 potentially confounding comorbidities. The association between mMDS and hsCRP, and hsCRP and DED, was further explored in separate regressions.

RESULTS

Of all participants, 9.1% had DED. In contrast to the hypothesis, higher mMDS levels were associated with greater odds of DED, corrected for demographics, smoking status, BMI, and comorbidities (OR 1.034, 95%CI: 1.015 to 1.055, P = 0.001). Moreover, there was a highly significant relationship between increasing mMDS and lower circulating hsCRP levels; however, there was no significant relationship between hsCRP and DED.

CONCLUSIONS

Stronger adherence to a Mediterranean diet does not appear to be associated with lower odds of having DED in the general population. Furthermore, there was no association between hsCRP and DED in this study. However, the previously described link between a Mediterranean diet and lower hsCRP was confirmed in this large population-based study.

Association of Ocular Surface Immune Cells With Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management (DREAM) Study

Purpose

Dry eye disease (DED) is a multifactorial, heterogeneous disease of the ocular surface with one etiology being ocular surface inflammation. Studies using animal models demonstrate the role of ocular surface immune cells in the inflammatory pathway leading to DED, but few have evaluated humans. This study described the white blood cell population from the ocular surface of patients with DED and assessed its association with DED signs and symptoms in participants of the Dry Eye Assessment and Management (DREAM) study.

Methods

Participants were assessed for symptoms using the Ocular Surface Disease Index, signs via corneal staining, conjunctival staining, tear break-up time, and Schirmer test, and Sjögren's syndrome (SS) based on the 2012 American College of Rheumatology classification criteria. Impression cytology of conjunctival cells from each eye was evaluated using flow cytometry: T cells, helper T cells (Th), regulatory T cells (Tregs), cytotoxic T cells, and dendritic cells.

Results

We assessed 1049 eyes from 527 participants. White blood cell subtype percentages varied widely across participants. Significant positive associations were found for Th and conjunctival staining (mean score of 2.8 for 0% Th and 3.1 for >4.0% Th; P = 0.007), and corneal staining (mean score of 3.5 for 0% Th and 4.3 for >4.0% Th; P = 0.01). SS was associated with higher percent of Tregs (median 0.1 vs. 0.0; P = 0.01).

Conclusions

Th were associated with more severe conjunctival and corneal staining, possibly indicating their role in inflammation leading to damage of the ocular surface. There is no consistent conclusion about Tregs in SS, but these results support that Tregs are elevated in SS.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

Dietary supplement and complementary and alternative medicine use among older adults in Australia and the United States

BACKGROUND

Dietary supplement and complementary and alternative medication (CAM) use can contribute to drug interactions, polypharmacy, nonadherence with prescription medications, and healthcare expenses, whereas evidence supporting benefits of using these products is sparse. There is a lack of current published literature describing the patterns or predictors of their use in community-dwelling older adults.

MATERIALS AND METHODS

We performed a cross-sectional analysis of community-dwelling adults from Australia and the US, aged 70 years and older (65 years for US minorities), enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) study. At study enrollment, eligible participants were required to be without concurrent 5-year life-limiting illness and free of documented evidence of cardiovascular disease, dementia, or significant physical disability. During the final study visit, a questionnaire was administered to collect information about supplement/CAM use. Data from 15,729 participants who completed this questionnaire between January 2017 and January 2018 were analyzed. Descriptive statistics were used to report the prevalence and types of products used. Factors associated with use were determined using multivariate regression.

RESULTS

Mean age of respondents was 79.6 years; 56.4% were female, 88.8% were from Australia, 56.5% reported 12 years of education or less, and 98.7% were living at home. Two-thirds (66.2%) of participants reported use of one or more supplement/CAM in the previous month. Products most commonly used included vitamin D (33.8% of participants), fish oil (22.7%), calcium (20.6%), glucosamine (14.8%), and multivitamin (12.9%). Female sex, US residency, higher education, polypharmacy (prescription medications), and frailty (in women) were significantly associated with higher use of supplements/CAMs.

CONCLUSIONS

Dietary supplement and CAM use is common among community-dwelling older adults in the United States and Australia. Given the high prevalence of use, collaboration between healthcare providers and older adult patients is important to insure safe and optimal use of these products.

NLRP3 Inflammasome as a Potential Therapeutic Target in Dry Eye Disease

Dry eye disease (DED) is a multifactorial ocular surface disorder arising from numerous interrelated underlying pathologies that trigger a self-perpetuating cycle of instability, hyperosmolarity, and ocular surface damage. Associated ocular discomfort and visual disturbance contribute negatively to quality of life. Ocular surface inflammation has been increasingly recognised as playing a key role in the pathophysiology of chronic DED. Current readily available anti-inflammatory agents successfully relieve symptoms, but often without addressing the underlying pathophysiological mechanism. The NOD-like receptor protein-3 (NLRP3) inflammasome pathway has recently been implicated as a key driver of ocular surface inflammation, as reported in pre-clinical and clinical studies of DED. This review discusses the intimate relationship between DED and inflammation, highlights the involvement of the inflammasome in the development of DED, describes existing anti-inflammatory therapies and their limitations, and evaluates the potential of the inflammasome in the context of the existing anti-inflammatory therapeutic landscape as a therapeutic target for effective treatment of the disease.