Dry eye diagnosis and management in 2004

Visual fatigue a comprehensive review of mechanisms of occurrence, animal model design and nutritional intervention strategies

When the eyes work intensively, it is easy to have eye discomfort such as blurred vision, soreness, dryness, and tearing, that is, visual fatigue. Visual fatigue not only affects work and study efficiency, but long-term visual fatigue can also easily affect physical and mental health. In recent years, with the popularization of electronic products, although it has brought convenience to the office and study, it has also caused more frequent visual fatigue among people who use electronic devices. Moreover, studies have reported that the number of people with visual fatigue is showing a trend of increasing year by year. The range of people involved is also extensive, especially students, people who have been engaged in computer work and fine instruments (such as microscopes) for a long time, and older adults with aging eye function. More and more studies have proposed that supplementation with the proper nutrients can effectively relieve visual fatigue and promote eye health. This review discusses the physiological mechanisms of visual fatigue and the design ideas of animal experiments from the perspective of modern nutritional science. Functional food ingredients with the ability to alleviate visual fatigue are discussed in detail.

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.

Dry Eye Assessment of Patients Undergoing Endoscopic Dacryocystorhinostomy for Nasolacrimal Duct Obstruction Combined with Dry Eye Syndrome

PURPOSE

To evaluate the prevalence of dry eye symptoms after endoscopic dacryocystorhinostomy (EDCR) for patients with primary acquired nasolacrimal duct obstruction (PANDO) combined with dry eye syndrome.

METHODS

The patients diagnosed with PANDO combined with dry eye syndrome who underwent EDCR were divided into two groups according to the questionnaire about dry eye symptoms after surgery. The medical records were retrospectively analyzed. Before and after surgery, we compared the tear meniscus height, tear breakup time, and the presence of corneal punctuate epithelial erosion. The level of dry eyes of patients after surgery was assessed by using the Korean guidelines for the diagnosis of dry eye.

RESULTS

At 6 months after EDCR, the proportion of patients with dry eye symptoms was 30% in a total of 80 patients. The duration of epiphora and tear breakup time after EDCR were higher in the group without dry eye symptoms and the proportion of eyes with corneal punctuate epithelial erosion after EDCR was higher in the group with dry eye symptoms. About 15% of total patients started treatment with a dry eye of level 2 or higher.

CONCLUSIONS

About 15% of patients who underwent EDCR for PANDO combined with dry eye syndrome developed significant dry eye syndrome after surgery. The short onset of epiphora was associated with the development of the dry eye symptoms. Therefore, it is necessary to evaluate dry eye syndrome before surgery, and surgeons should be careful about this.

A comparative investigator-initiated pilot study on the efficacy and safety of biodegradable microneedle acupuncture and conventional intradermal acupuncture for dry eye patient: A superiority, assessor-blinded, randomized controlled trial

BACKGROUND

The prevalence of dry eye, which is a common lacrimal disease, is steadily increasing in modern society. However, fundamental treatment for it has not yet been established. This study aims to assess the efficacy and safety of a novel medical device, the biodegradable microneedle acupuncture (BMA), using a traditional intradermal acupuncture needle as the control acupuncture for dry eye.

METHOD

This study will be an investigator-initiated, assessor-blinded, comparative, superiority pilot randomized controlled trial. A total of 30 patients with dry eye will be randomly assigned to the experimental or the control group in equal proportion. For the experimental group, the BMA will be applied to both sides of 5 acupoints including BL2, GB14, TE23, EX-HN5, and ST1. For the control group, conventional intradermal acupuncture will be applied to the same acupoints. The needles will be attached for 4 hours. Over 4 weeks, both the interventions will be performed 12 times in total. The primary outcome would be the ocular surface disease index. The secondary outcomes would be the visual analog scale for subjective symptoms, quality of life, Schirmer I test, and general assessment.

DISCUSSION

The findings of this study on the efficacy and safety of the BMA would be helpful for patients with dry eye in clinical practice. Further, these results would provide for the foundation of a large-scale BMA study.

Dry eye disease and risks of urban air pollution – literature review

Air pollution has a major impact on health, and it particularly affects the mucous membranes of the respiratory tract and the eyes. The ocular effects of chronic, long-term exposure to high levels of air pollution are still unclear. The increase in air pollution levels can be associated with an increase in the instability of the tear film. The aim of this paper is to evaluate and discuss the available data about chronic eye diseases in regions with high air pollution. Furthermore, the review also offers a certain understanding of the link between chronic dry eye disease (DED) and air pollution. Materials and methods: Specific keywords (dry eye, air pollution, and urban) were used to search the medical databases of PubMed and Medline. This research technique led to obtaining 103 papers, dating from 1995 to 2021. Out of those, 15 were used as the basis of this paper. Results: The pathophysiological mechanisms of oxidative stress and ocular surface inflammation involve the selective binding of environmental agents to ocular surface membrane receptors, leading to the activation of proinflammatory signaling pathways with changes in the extracellular stromal matrix and consequent occurrence of inflammation of the ocular surface with epithelial defects. Conclusions: Dry eye disease, pollution, and eye allergy overlap, but their presentations can be different. Future advancements in monitoring technology and the development of modern, non-invasive diagnostic methods will help prove the link between air pollutants and  DED. The points should be aimed at preventing the global risks of antigenic stimulation of "urban eye".

Voxel-Mirrored Homotopic Connectivity Is Altered in Meibomian Gland Dysfunction Patients That Are Morbidly Obese

Purpose: To investigate the altered functional connectivity (FC) of the cerebral hemispheres in patients with morbid obesity (MO) with meibomian gland dysfunction (MGD) by voxel-mirrored homotopic connectivity (VMHC). Methods: Patients and matched healthy controls (HCs) were recruited, and all subjects underwent functional resonance magnetic imaging (fMRI), and VMHC results were processed statistically to assess the differences in FC in different brain regions between the two groups. We further used ROC curves to evaluate the diagnostic value of these differences. We also used Pearson’s correlation analysis to explore the relationship between changes in VMHC values in specific brain regions, visual acuity, and Mini-Mental State Examination (MMSE) score. Conclusions: Patients with morbid obesity and MGD had abnormal FC in the cerebral hemispheres in several specific brain areas, which were mainly concentrated in pathways related to vision and perception and may correlate to some extent with the clinical presentations of the patients.

The Relationship Between Dry Eye in Adults with Indications for Kidney Transplantation and Influence Factors

Purpose

Patients with end-stage renal failure are susceptible to dry eye disease. This study explores the relationship between dry eye disease and influence factors.

Patients and Methods

The control group consisted of 57 healthy subjects who were kidney donors. They were of the same age and sex as the kidney transplant recipients. The outcome variable was the dry eye condition of the participants. The Schirmer test confirmed dry eye disease, TBUT (breakup time test), and the Eye Surface Disease Index (OSDI) questionnaire, using linear regression to evaluate the association.

Results

The total number of subjects was 146 (89 kidney recipients and 57 kidney donors). When univariate analysis found the level of visual acuity, the age group involved was statistically significant, while the other factors were not statistically significant. In multivariable logistic regression analysis, age (odds ratio: 2.8, p<0.05), smoking history (odd ratio: 0.1, p<0.05), corneal conjunctival calcification (odd ratio: 0.2, p<0.05); central corneal thickness (odd ratio: 1.02, p<0.05) is considered to be an influence factor for disease progression.

Conclusion

Age group, smoking history, corneal central thickness, and conjunctival calcification are factors for dry eye disease in patients preparing to receive a kidney. These results reinforce the evidence for multifactorial dry eye disease in patients with renal impairment.

Plug-related canaliculitis: a rare or underdiagnosed disease?

CLINICAL RELEVANCE

Conjunctivitis, chalazion and blepharitis are routinely managed by optometrists. However, it is especially important to consider the diagnosis of canaliculitis in patients with chronic or recurrent conditions.

BACKGROUND

This study aimed to report the clinical features, radiological findings and treatment outcomes in patients with plug-related canaliculitis.

METHODS

This retrospective study included patients with canaliculitis secondary to plug insertion between 2007 and 2020. All data regarding epidemiological characteristics, clinical presentation, isolated microorganisms, computed tomography imaging findings, treatment, and outcomes were analysed.

RESULTS

A total of 20 plug-related canaliculitis from 19 patients (18.3%) among all 109 cases of canaliculitis were identified. All patients with plug-related canaliculitis were females with a past history of lacrimal plug insertion for dry eye (mean age: 58.2 years). Most patients were initially treated as conjunctivitis with the mean time lapse to a diagnosis of 5.2 months. The average time from plug insertion to onset of symptoms was 5.1 years. Eighteen patients underwent canaliculotomy, and one patient received lacrimal irrigation. Plugs were identified in 18 cases, with SmartPlug in 13 cases (72%), followed by EaglePlugTM (two cases), Herrick Lacrimal Plug (two cases), and migrated FCI Painless Plug (1 case). Cultures of discharge, concretions, and/or infected plugs mostly revealed Pseudomonas aeruginosa (42%). Orbital computed tomography in four cases with SmartPlug revealed central radiolucency with surrounding soft-tissue enhancement. No recurrent canaliculitis was observed throughout a mean follow-up period of 13.7 months. No patient needed re-plugging after canaliculotomy and plug removal, with only one required additional lubricants for recurrent dry eye.

CONCLUSION

Plug-related canaliculitis is often underdiagnosed due to late onset and similar symptoms to common ocular diseases. Awareness of plug insertion history as well as meticulous removal of the plug, concretion and/or granulation tissue is important for early diagnosis and to ensure a good outcome.

Impact of corneal refractive surgery on the precorneal tear film

Corneal refractive surgeries are one of the commonly performed procedures for correction of refractive errors. Tear film abnormality is the most common postoperative complication of corneal refractive surgeries. Consequently, these procedures represent a clinically significant cause of dry eye disease. The mechanisms which lead to dry eye disease include corneal sensory nerve dysfunction, ocular surface desiccation, glandular apoptosis and ocular surface inflammation. Although transient tear film abnormalities occur in almost all patients following surgery, patients with pre-existing dry eye symptoms or dry eye disease are at significant risk of developing more severe or long-term ocular surface disease. As such, careful patient selection and preoperative evaluation is essential to ensuring successful surgical outcomes. This is particularly important with LASIK which has the strongest association with dry eye disease. Appropriate surface lubrication and anti-inflammatory therapy remains the cornerstone treatment. Timely and effective management is important to facilitate visual rehabilitation and reduce the risk of secondary complications. In this review we describe the causes, pathophysiology, risk factors, manifestations, and management of tear film dysfunction and dry eye disease following corneal refractive surgery.

A prospective study to assess the role of vitamin D individually and in combination with cyclosporine in the treatment of dry eye in patients with deficient serum 25(OH)D levels

Purpose:

To study the efficiency of vitamin D3 (buccal spray) alone and combination of vitamin D3 with cyclosporine in the treatment of dry eye disease (DED) in patients with deficient serum 25(OH)D levels.

Methods:

Around 90 patients with DED with deficient serum 25(OH)D levels were included and randomized into three groups and were given treatment for dry eye (Group A- 0.5% carboxymethylcellulose (CMC), Group B- 0.5% CMC + 2000 IU vitamin D through buccal spray, Group C- 0.5% CMC + 2000 IU vitamin D through buccal spray + 0.05% cyclosporine). The patients were followed at day-15, day-30, and day-90 for improvement in tear breakup time (TBUT) and Schirmer’s, and ocular surface disease index (OSDI) score. Improvement in serum vitamin D level was assessed at day-90. One way ANOVA test, paired t-test, and Chi-square test were used for analysis.

Results:

Group B and Group C had significantly higher in Schirmer’s test-I values as compared to Group A (P = 0.001, P < 0.001, P < 0.001 at day-15, day-30, and day-90, respectively). Significantly higher values of TBUT and mean serum vitamin D levels were obtained in Group B and Group C as compared to Group A at day-90 (P < 0.05). OSDI scores of patients significantly decreased in all three groups at all follow-up visits (P < 0.05). Overall, Group C and Group B were found statistically better than Group A. Group C showed better results than Group B but they were nonsignificant.

Conclusion:

Vitamin D supplementation leads to earlier and significant improvement in TBUT, Schirmer’s, and OSDI score in patients with vitamin D deficient DED.

The Effect of Periocular Fatty Acids and 0.15% Hyaluronate Eye Drops Application on Keratoconjunctivitis Sicca in Dogs: An Exploratory Study

The aim of this exploratory study was to evaluate the efficacy of a periophthalmic cream of a pool of fatty acids (FAG®) in association with 0.15% hyaluronate eye drops in alleviating the clinical symptoms of keratoconjunctivitis sicca (KCS) in a case series of dogs. The study was conducted on 10 dogs diagnosed with idiopathic KCS. All dogs had been previously treated with topical tobramycin alone, which had been ineffective in improving clinical signs. The affected eyes were treated with 2 applications daily of a periophthalmic cream of FAG® and 1 drop 3 times a day of 0.15% of hyaluronate eye drops for 8 weeks. Schirmer tear test I (STT I) values were recorded and ocular signs (conjunctival hyperemia, ocular discharge, corneal opacity, vascularization and pigmentation, and discomfort level) were collected, scored on a 3-point scale (grade 0, grade 1, and grade 2). Differences between scores and STT data recorded at baseline and at 8 weeks of therapy were statistically analysed. The effect of treatment was pronounced (increase in STT values by more than 4 mm/min, no signs of inflammation) in 8/18 eyes; moderate (increase in STT values of 3-4 mm/min or mild improvement in signs of corneal/conjunctival inflammation) in 3/18 eyes; and unsatisfactory in 7 of 18 eyes. Median of STT values significantly improved compared with baseline levels, while statistically significant decreases in clinical-sign scores of conjunctival hyperemia, ocular discharge, and discomfort were recorded. However, in moderate and advanced stages, reduction of neovascularization or corneal pigmentation was not observed throughout the treatment period. No noticeable adverse reactions were recorded. Preliminary results indicate that the application of periocular FAG and topical 0.15% hyaluronate eye drops may be a suitable treatment for KCS in dogs in selected cases. A larger comparative study is necessary to further confirm these findings.

Schirmer test changes after 20 gauge and 23 gauge pars plana vitrectomy

Objective: To evaluate the short-term changes in Schirmer I test (ST) after pars plana vitrectomy and to compare the results between 23 gauge and 20 gauge vitrectomy surgeries.

Methods: 42 patients who underwent pars plana vitrectomy for posterior segment diseases were included in this prospective, non-randomized, comparative study. The choice of sclerotomy gauge was at the surgeons’ discretion. ST values were recorded before and at 1 and 3 months after vitrectomy.

Results: 20 patients in 23 gauge and 22 patients in 20-gauge group with a mean age of 59.9 ± 13.5 years were included. The mean preoperative ST values decreased significantly in both groups at 1 and 3 months after surgery (all P < 0.01). The ST values in the fellow eyes were the same, at baseline and during the follow up (P > 0.05). At 3 months visit, 15 eyes (35.7%) had abnormal ST measurements. There was no statistically significant difference in the changes in the ST measurements between the two groups at one month (P = 0.7), however, 3 months after surgery, the mean decrease in the ST measurements was significantly higher in the 20 gauge group (P = 0.03). At 3 months, 4 eyes in the 23 gauge group (20%) and 11 eyes in the 20 gauge group (50%) had abnormal ST measurements (P = 0.05).

Conclusions: Although both 20 and 23-gauge vitrectomy decrease the ST measurements postoperatively, the value is less affected by the 23-gauge vitrectomy.

Modern Therapeutic Approaches for Noninfectious Ocular Diseases Involving Inflammation

Dry eye disease, age-related macular degeneration, and uveitis are ocular diseases that significantly affect the quality of life of millions of people each year. In these diseases, the action of chemokines, proinflammatory cytokines, and immune cells drives a local inflammatory response that results in ocular tissue damage. Multiple therapeutic strategies are developed to either address the symptoms or abate the underlying cause of these diseases. Herein, the challenges to deliver drugs to the relevant location in the eye for each of these diseases are reviewed along with current and innovative therapeutic approaches that attempt to restore homeostasis within the ocular microenvironment.

Periorbital facial rejuvenation; applied anatomy and pre-operative assessment

PURPOSE

Since different subspecialties are currently performing a variety of upper facial rejuvenation procedures, and the level of knowledge on the ocular and periocular anatomy and physiology is different, this review aims to highlight the most important preoperative examinations and tests with special attention to the eye and periocular adnexal structures for general ophthalmologist and specialties other than oculo-facial surgeons in order to inform them about the fine and important points that should be considered before surgery to have both cosmetic and functional improvement.

METHODS

English literature review was performed using PubMed with the different keywords of "periorbital rejuvenation", "blepharoptosis", "eyebrow ptosis", "blepharoplasty", "eyelid examination", "facial assessment", and "lifting". Initial screening was performed by the senior author to include the most pertinent articles. The full text of the selected articles was reviewed, and some articles were added based upon the references of the initial articles. Included articles were then reviewed with special attention to the preoperative assessment of the periorbital facial rejuvenation procedures.

RESULTS

There were 254 articles in the initial screening from which 84 articles were found to be mostly related to the topic of this review. The number finally increased to 112 articles after adding the pertinent references of the initial articles.

CONCLUSION

Static and dynamic aging changes of the periorbital area should be assessed as an eyelid-eyebrow unit paying more attention to the anthropometric landmarks. Assessing the facial asymmetry, performing comprehensive and detailed ocular examination, and asking about patients' expectation are three key elements in this regard. Furthermore, taking standard facial pictures, obtaining special consent form, and finally getting feedback are also indispensable tools toward a better outcome.

Cytomegalovirus Anterior Uveitis Following Topical Cyclosporine A

Cytomegalovirus (CMV) anterior uveitis and endotheliitis occurs among immunocompetent individuals and may manifest as Posner-Schlossman syndrome or Fuchs uveitis syndrome. The condition may first present following ophthalmic surgery, the use of a fluocinolone-sustained steroid drug delivery implant, or the use of topical prostaglandin analogues for the treatment of glaucoma. We report the first case of a non-human immunodeficiency virus-infected individual who presented with CMV anterior uveitis after the use of topical cyclosporine A 0.05% ophthalmic emulsion for the treatment of symptomatic dry eyes.

Autologous serum eye drops for dry eye

BACKGROUND

Theoretically, autologous serum eye drops (AS) offer a potential advantage over traditional therapies on the assumption that AS not only serve as a lacrimal substitute to provide lubrication but contain other biochemical components that allow them to mimic natural tears more closely. Application of AS has gained popularity as second-line therapy for patients with dry eye. Published studies on this subject indicate that autologous serum could be an effective treatment for dry eye.

OBJECTIVES

We conducted this review to evaluate the efficacy and safety of AS given alone or in combination with artificial tears as compared with artificial tears alone, saline, placebo, or no treatment for adults with dry eye.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2016), Embase (January 1980 to July 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We also searched the Science Citation Index Expanded database (December 2016) and reference lists of included studies. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 July 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared AS versus artificial tears for treatment of adults with dry eye.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts and assessed full-text reports of potentially eligible trials. Two review authors extracted data and assessed risk of bias and characteristics of included trials. We contacted investigators to ask for missing data. For both primary and secondary outcomes, we reported mean differences with corresponding 95% confidence intervals (CIs) for continuous outcomes. We did not perform meta-analysis owing to differences in outcome assessments across trials.

MAIN RESULTS

We identified five eligible RCTs (92 participants) that compared AS versus artificial tears or saline in individuals with dry eye of various origins (Sjögren's syndrome-related dry eye, non-Sjögren's syndrome dry eye, and postoperative dry eye induced by laser-assisted in situ keratomileusis (LASIK)). We assessed the certainty of evidence as low or very low because of lack of reporting of quantitative data for most outcomes and unclear or high risk of bias among trials. We judged most risk of bias domains to have unclear risk in two trials owing to insufficient reporting of trial characteristics, and we considered one trial to have high risk of bias for most domains. We judged the remaining two trials to have low risk of bias; however, these trials used a cross-over design and did not report data in a way that could be used to compare outcomes between treatment groups appropriately. Incomplete outcome reporting and heterogeneity among outcomes and follow-up periods prevented inclusion of these trials in a summary meta-analysis.Three trials compared AS with artificial tears; however, only one trial reported quantitative data for analysis. Low-certainty evidence from one trial suggested that AS might provide some improvement in participant-reported symptoms compared with artificial tears after two weeks of treatment; the mean difference in mean change in symptom score measured on a visual analogue scale (range 0 to 100, with higher scores representing worse symptoms) was -12.0 (95% confidence interval (CI) -20.16 to -3.84; 20 participants). This same trial found mixed results with respect to ocular surface outcomes; the mean difference in mean change in scores between AS and artificial tears was -0.9 (95% CI -1.47 to -0.33; 20 participants; low-certainty evidence) for fluorescein staining and -2.2 (95% CI -2.73 to -1.67; 20 participants; low-certainty evidence) for Rose Bengal staining. Both staining scales range from 0 to 9, with higher scores indicating worse results. The mean change in tear film break-up time was 2.00 seconds longer (95% CI 0.99 to 3.01; 20 participants; low-certainty evidence) in the AS group than in the artificial tears group. Investigators reported no clinically meaningful differences in Schirmer's test scores between groups (mean difference -0.40 mm, 95% CI -2.91 to 2.11; 20 participants; low-certainty evidence). None of these three trials reported tear hyperosmolarity and adverse events.Two trials compared AS versus saline; however, only one trial reported quantitative data for analysis of only one outcome (Rose Bengal staining). Trial investigators of the two studies reported no differences in symptom scores, fluorescein staining scores, tear film break-up times, or Schirmer's test scores between groups at two to four weeks' follow-up. Very low-certainty evidence from one trial suggested that AS might provide some improvement in Rose Bengal staining scores compared with saline after four weeks of treatment; the mean difference in Rose Bengal staining score (range from 0 to 9, with higher scores showing worse results) was -0.60 (95% CI -1.11 to -0.09; 35 participants). Neither trial reported tear hyperosmolarity outcomes. One trial reported adverse events; two of 12 participants had signs of conjunctivitis with negative culture that did resolve.

AUTHORS' CONCLUSIONS

Overall, investigators reported inconsistency in possible benefits of AS for improving participant-reported symptoms and other objective clinical measures. There might be some benefit in symptoms with AS compared with artificial tears in the short-term, but we found no evidence of an effect after two weeks of treatment. Well-planned, large, high-quality RCTs are warranted to examine participants with dry eye of different severities by using standardized questionnaires to measure participant-reported outcomes, as well as objective clinical tests and objective biomarkers to assess the benefit of AS therapy for dry eye.

Serum components and clinical efficacies of autologous serum eye drops in dry eye patients with active and inactive Sjogren syndrome

PURPOSE:

Autologous serum eye drops are considered safe and efficient for the treatment of various ocular surface disorders, including dry eye diseases (DED) caused by the primary and secondary Sjogren syndrome (SS). However, the serum components in patients of SS may be different from those of normal patients and can thus lead to unpredictable therapeutic effects. This study divided the SS patients into active and inactive types based on the erythrocyte sedimentation rate and the presence or absence of active rheumatoid arthritis.

METHODS:

We compared the serum components of these two groups with standard and multiplex enzyme linked immunosorbent assay arrays and predicted the therapeutic effects of topical autologous serum for the treatment of DED with ocular surface disease index (OSDI) and Oxford Schema scale (OSS).

RESULTS:

Hyaluronic acid and transforming growth factor b1 levels were significantly higher in the active SS group compared to the inactive SS group (P < 0.01), whereas epidermal growth factors, insulin growth factor 1, and fibroblast growth factor b had no significant differences between these two groups. Active SS group had significantly higher expressions of interleukin (IL) 1 beta, IL 6, and tumor necrosis factor alpha compared to inactive SS patients (P < 0.05). There were no statistical differences in therapeutic effects between these two groups, as measured with the OSDI or OSS.

CONCLUSION:

Dividing the Sjogren dry eye patients into active and inactive groups may appear as a reasonable method to predict the quality of autologous serum eye drops, but there seems to be no significant predictability to the therapeutic effects.

Presence or absence of ocular surface inflammation directs clinical and therapeutic management of dry eye

Background

The presence of clinically significant inflammation has been confirmed in the tears of 40%–65% of patients with symptoms of dry eye. Ocular surface inflammation may lead to tear film instability, epithelial cell irregularities, and permeability, resulting in chronic symptomatic pain and fluctuating vision as well as negative surgical outcomes.

Patients and methods

A retrospective single center medical chart review of 100 patients was conducted. All patients were tested with the InflammaDry test to determine if patients exhibited elevated levels of matrix metalloproteinase 9 (MMP-9). InflammaDry-positive patients were started on a combination of cyclosporine 0.05% twice daily, 2,000–4,000 mg oral omega-3 fatty acids, and frequent artificial tear replacement. InflammaDry-negative patients were started on 2,000–4,000 mg of oral omega-3 fatty acids and frequent artificial tear replacement. Each patient was retested at ~90 days. A symptom questionnaire was performed at the initial visit and at 90 days.

Results

60% of the patients with dry eye symptoms tested positive for elevated MMP-9 at the initial visit. 78% of all patients returned for follow-up at ~90 days including 80% (48/60) of the previously InflammaDry-positive patients and 75% (30/40) of the previously InflammaDry-negative patients. A follow-up symptom questionnaire reported at least 75% symptomatic improvement in 65% (31/48) of the originally InflammaDry-positive patients and in 70% (21/30) of the initially InflammaDry-negative patients. Symptomatic improvement of at least 50% was reported in 85% (41/48) of previously InflammaDry-positive patients and 86% (26/30) of previously InflammaDry-negative patients. Following treatment, 54% (26/48) of previously InflammaDry-positive patients converted to a negative InflammaDry result.

Conclusion

Identifying which symptomatic dry eye patients have underlying inflammation may predict patient responses to treatment and influence clinical management strategies.

Over the counter (OTC) artificial tear drops for dry eye syndrome

BACKGROUND

Over the counter (OTC) artificial tears historically have been the first line of treatment for dry eye syndrome and dry eye-related conditions like contact lens discomfort, yet currently we know little regarding the overall efficacy of individual, commercially available artificial tears. This review provides a much needed meta-analytical look at all randomized and quasi-randomized clinical trials that have analyzed head-to-head comparisons of OTC artificial tears.

OBJECTIVES

To evaluate the effectiveness and toxicity of OTC artificial tear applications in the treatment of dry eye syndrome compared with another class of OTC artificial tears, no treatment, or placebo.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2015), EMBASE (January 1980 to December 2015), Latin American and Caribbean Health Sciences (LILACS) (January 1982 to December 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the US Food and Drugs Administration (FDA) website (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 December 2015. We searched reference lists of included trials for any additional trials not identified by the electronic searches.

SELECTION CRITERIA

This review includes randomized controlled trials with adult participants who were diagnosed with dry eye, regardless of race and gender. We included trials in which the age of participants was not reported, and clinical trials comparing OTC artificial tears with another class of OTC artificial tears, placebo, or no treatment. This review did not consider head-to-head comparisons of artificial tears with another type of dry-eye therapy.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane. Two authors independently screened the search results, reviewed full-text copies for eligibility, examined risk of bias, and extracted data. We performed meta-analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data. We summarized all other included trial results in the text.

MAIN RESULTS

We included 43 randomized controlled trials (3497 participants with dry eye). Due to the heterogeneity of study characteristics among the included trials with respect to types of diagnostic criteria, interventions, comparisons, and measurements taken, our ability to perform meta-analyses was limited. The review found that, in general, there was uncertainty whether different OTC artificial tears provide similar relief of signs and symptoms when compared with each other or placebo. Nevertheless, we found that 0.2% polyacrylic acid-based artificial tears were consistently more effective at treating dry eye symptoms than 1.4% polyvinyl alcohol-based artificial tears in two trials assessing this comparison (175 participants). All other included artificial tears produced contradictory between-group results or found no between-group differences. Our review also found that OTC artificial tears may be generally safe, but not without adverse events. Overall, we assessed the quality of evidence as low due to high risks of bias among included trials and poor reporting of outcome measures which were insufficient for quantitative analysis. Furthermore, we identified an additional 18 potentially eligible trials that were reported only in clinical trial registers with no associated results or publications. These trials reportedly enrolled 2079 total participants for whom no data are available. Such lack of reporting of trial results represents a high risk of publication bias.

AUTHORS' CONCLUSIONS

OTC artificial tears may be safe and effective means for treating dry eye syndrome; the literature indicates that the majority of OTC artificial tears may have similar efficacies. This conclusion could be greatly skewed by the inconsistencies in study designs and inconsistencies in reporting trial results. Additional research is therefore needed before we can draw robust conclusions about the effectiveness of individual OTC artificial tear formulations.

Long-term outcome after topical ciclosporin in severe dry eye disease with a 10-year follow-up

Aim

To report a 10-year follow-up of patients suffering from severe dry eye syndrome (DES) initially treated with topical ciclosporin A (tCSA) for 6 months.

Methods

The charts of 26 patients with severe DES related to keratoconjunctivitis sicca (KCS) and followed for a minimum 10-year follow-up were retrospectively reviewed. All of them were treated initially with tCSA for 6 months. The Schirmer I test, fluorescein and lissamine green staining scores and tear film break-up time (TBUT) were recorded to assess clinical symptoms before, during and after treatment. The subjective signs were evaluated with the ocular surface disease index (OSDI) questionnaire. Prolongation and reintroduction of tCSA after the initial treatment and combined treatments were also noted.

Results

Overall the median (IQR) duration of tCSA treatment was 23 (7–51) months after a prolonged induction treatment lasting 20 (8–41) months during the 10-year follow-up. For symptoms, a statistically significant difference in the OSDI between baseline and the end of the 10-year follow-up was not found (p=0.67). We noted a statistically significant improvement in all clinical signs after the initial treatment period, still present at the end of follow-up. Only 6.5% of the patients needed reintroduction of tCSA after their prolonged induction treatment.

Conclusions

The improvement observed after an initial tCSA treatment was sustained after a long-term follow-up with few cases requiring additional tCSA treatment. A prolonged induction treatment to decrease initial inflammatory local signs is a promising option in KCS.

3-Iodothyronamine increases transient receptor potential melastatin channel 8 (TRPM8) activity in immortalized human corneal epithelial cells

3-Iodothyronamine (3T1AM) is an endogenous thyroid hormone metabolite that interacts with the human trace amine-associated receptor 1 (hTAAR1), a G-protein-coupled receptor, to induce numerous physiological responses including dose-dependent body temperature lowering in rodents. 3T1AM also directly activates cold-sensitive transient receptor potential melastatin 8 (TRPM8) channels in human conjunctival epithelial cells (HCjEC) at constant temperature as well as reducing rises in IL-6 release induced by transient receptor potential vanilloid 1 (TRPV1) activation by capsaicin (CAP). Here, we describe that 3T1AM-induced TRPM8 activation suppresses through crosstalk TRPV1 activation in immortalized human corneal epithelial cells (HCEC). RT-PCR and immunofluorescent staining identified TRPM8 gene and protein expression. Increases in Ca(2+) influx induced by the TRPM8 agonists either 3T1AM (0.1-10 μM), menthol (500 μM), icilin (15-60 μM) or temperature lowering (either <17°C or >17°C) were all blocked by 10-20 μM BCTC, a mixed TRPV1/TRPM8 antagonist. BCTC blocked 3T1AM-induced recombinant TRPM8 activation of Ca(2+) transients in an osteosarcoma heterologous expression system. The effects of BCTC in HCEC were attributable to selective TRPM8 inhibition since whole-cell patch-clamp currents underlying Ca(2+) rises induced by 20 μM CAP were BCTC insensitive. On the other hand, Ca(2+) transients induced by activating TRPV1 with either CAP or a hyperosmolar medium were suppressed during exposure to either 1 μM 3T1AM or 15 μM icilin. All of these modulatory effects on intracellular Ca(2+) regulation induced by the aforementioned agents were attributable to changes in underlying inward and outward current. Taken together, TRPM8 activation by 3T1AM markedly attenuates and even eliminates hyperosmolar and CAP induced TRPV1 activation through crosstalk.

Dry Eye Disease following Refractive Surgery: A 12-Month Follow-Up of SMILE versus FS-LASIK in High Myopia

Purpose. To compare dry eye disease following SMILE versus FS-LASIK. Design. Prospective, nonrandomised, observational study. Patients. 90 patients undergoing refractive surgery for myopia were included. 47 eyes underwent SMILE and 43 eyes underwent FS-LASIK. Methods. Evaluation of dry eye disease was conducted preoperatively and at 1, 3, 6, and 12 months postoperatively, using the Salisbury Eye Evaluation Questionnaire (SEEQ) and TBUT. Results. TBUT reduced following SMILE at 1 and 3 months (p < 0.001) and at 1, 3, and 6 months following FS-LASIK (p < 0.001). TBUT was greater following SMILE than FS-LASIK at 3, 6, and 12 months (p < 0.001, p < 0.001, and p = 0.009, resp.). SEEQ scores increased (greater symptoms) following SMILE at 1 month (p < 0.001) and 3 months (p = 0.003) and at 1, 3, and 6 months following FS-LASIK (p < 0.001). SMILE produced lower SEEQ scores (fewer symptoms) than FS-LASIK at 1, 3, and 6 months (p < 0.001). Conclusion. SMILE produces less dry eye disease than FS-LASIK at 6 months postoperatively but demonstrates similar degrees of dry eye disease at 12 months.

Dry eye after laser in-situ keratomileusis

Laser-assisted in-situ keratomileusis (LASIK) is one of the most commonly performed refractive procedures with excellent visual outcomes. Dry eye syndrome is one of the most frequently seen complications after LASIK, with most patients developing at least some mild dry eye symptoms postoperatively. To achieve improved visual outcomes and greater patient satisfaction, it is essential to identify patients prone to dry eyes preoperatively, and initiate treatment early in the course. Enhanced understanding of the pathophysiology of post-LASIK dry eye will help advance our approach to its management.

A Comprehensive Review on Dry Eye Disease: Diagnosis, Medical Management, Recent Developments, and Future Challenges

Dry eye syndrome (DES) or keratoconjunctivitis sicca (KCS) is a common disorder of the tear film caused by decreased tear production or increased evaporation and manifests with a wide variety of signs and symptoms. The present review from interpretation of the literature gives detailed information on the prevalence, definition, causes, diagnostic tests, and medical management of dry eye disease. A number of systems contribute to the physiological integrity of the ocular surface and disruption of system may or may not produce symptoms. Therefore accurate diagnosis of dry eyes with no or minimal disruption of physiological function is necessary. The paper also discusses different colloidal drug delivery systems and current challenges in the development of topical ophthalmic drug delivery systems for treatment of KCS. Due to the wide prevalence and number of factors involved, newer, more sensitive diagnostic techniques and novel therapeutic agents have been developed to provide ocular delivery systems with high therapeutic efficacy. The aim of this review is to provide awareness among the patients, health care professionals, and researchers about diagnosis and treatment of KCS and recent developments and future challenges in management of dry eye disease.

Topical cyclosporine A in the treatment of dry eye: a systematic review and meta-analysis

PURPOSE

Cyclosporine A (CsA) is considered a potentially effective treatment for dry eye syndrome (DES), which is now one of the most common ocular problems whose exact mechanism is unknown. Because randomized controlled trials (RCTs) reported to date have shown varying results in the efficacy and safety of CsA in different types of DES, we conducted a systematic review and meta-analysis of RCTs on CsA versus placebo in treating DES to evaluate the treatment efficacy and safety of CsA.

METHODS

We searched for RCTs published after 1990, in MEDLINE, EMBASE, the Cochrane library, and ClinicalTrials.gov. The RCTs that were included compared topical CsA and placebo for DES treatment by evaluating scores of ocular surface disease index, tear break-up time, or Schirmer test. Cochrane risk of bias tool was used for assessing the risk of bias.

RESULTS

We included 12 RCTs involving 3034 eyes of 1660 participants. We observed statistically significant improvements on scores of break-up time (standardized mean difference [SMD], 0.80; 95% confidence interval [CI], 0.13-1.46; I = 95%) and scores of Schirmer test with anesthesia (SMD, 0.78; 95% CI, 0.09-1.46; I = 97%) after treatment with topical CsA. Scores of ocular surface disease index (SMD, 0.77; 95% CI, -1.05 to 2.58; I = 98%) and scores of Schirmer test without anesthesia (SMD, 0.08; 95% CI, -0.11 to 0.27; I = 0%) were not improved. Adverse events (odds ratio [OR], 1.61; 95% CI, 1.28-2.02; I = 21%) were observed.

CONCLUSIONS

Topical CsA could be an effective treatment for DES, especially for DES associated with conjunctival injury. Further RCTs with larger sample sizes for different clinical types of DES are warranted to determine the efficacy and limitation for different clinical types of DES.

The relationship between Graves' ophthalmopathy and dry eye syndrome

Background

A complex relationship between Graves’ ophthalmopathy (GO) and dry eye syndrome exists. New research brings more insight into the association between these two diseases.

Methods

A review of the literature was conducted using the query terms “Graves’ Ophthalmopathy”, “Thyroid Eye Disease”, and “Dry Eye” in MedLine (PubMed) and Scopus. A total of 55 papers were reviewed. Case reports were excluded.

Conclusion

This review paper shows the close relationship between dry eye syndrome and GO. The underlying mechanisms behind their association suggest mechanical impairment of orbital muscles and immune-mediated lacrimal gland dysfunction as the causes of dry eye in GO patients. However, there are a variety of treatment options available for patients with GO with signs of dry eye, which help combat this issue.

Autologous serum eye drops for dry eye

BACKGROUND

=Theoretically, autologous serum eye drops (AS) have a potential advantage over traditional therapies based on the assumption that ASserve not only as a lacrimal substitute to provide lubrication, but also contain other biochemical components mimicking natural tears more closely. The application of AS in dry eye treatment has gained popularity as a second-line therapy in the treatment of dry eye.Published studies on the subject indicate that autologous serum could be an effective treatment for dry eye.

OBJECTIVES

To evaluate the efficacy and safety of AS compared to artificial tears for treating dry eye.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 3),Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE,(January 1950 to April 2013), EMBASE (January 1980 to April 2013), Latin American and Caribbean Literature on Health Sciences(LILACS) (January 1982 to April 2013), themetaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov(www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We also searched the Science Citation Index Expanded database (September 2013) and reference lists of included studies. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 April 2013.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which AS was compared to artificial tears in the treatment of dry eye in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts and assessed full-text articles of potentially eligible trials. Two review authors extracted data and assessed the methodological quality and characteristics of the included trials.We contacted investigators for missing data. For both primary and secondary outcomes, we reported mean differences with corresponding 95% confidence intervals(CIs) for continuous outcomes.

MAIN RESULTS

We identified four eligible RCTs in which AS was compared with artificial tear treatment or saline in individuals (n = 72 participants)with dry eye of various etiologies (Sjögren’s syndrome-related dry eye, non-Sjögren’s syndrome dry eye and postoperative dry eye induced by laser-assisted in situ keratomileusis (LASIK)). The quality of the evidence provided by these trials was variable. A majority of the risk of bias domains were judged to have an unclear risk of bias in two trials owing to insufficient reporting of trial characteristics.One trial was considered to have a low risk of bias for most domains while another was considered to have a high risk of bias for most domains. Incomplete outcome reporting and heterogeneity in the participant populations and follow-up periods prevented the inclusion of these trials in a summary meta-analysis. For the primary outcome, improvement in participant-reported symptoms at one month, one trial (12 participants) showed no difference in participant-reported symptoms between 20% AS and artificial tears. Based on the results of two trials in 32 participants, 20% AS may provide some improvement in participant-reported symptoms compared to traditional artificial tears after two weeks of treatment. One trial also showed positive results with a mean difference in tear breakup time (TBUT) of 2.00 seconds (95% CI 0.99 to 3.01 seconds) between 20% AS and artificial tears after two weeks, which were not similar to findings from the other trials. Based on all other objective clinical assessments included in this review, AS was not associated with improvements in aqueous tear production measured by Schirmer's test (two trials, 33 participants), ocular surface condition with fluorescein (four trials, 72 participants) or Rose Bengal staining (three trials, 60 participants), and epithelial metaplasia by impression cytology compared to artificial tears (one trial, 12 participants). Data on adverse effects were not reported by three of the included studies. In one study, there were no serious adverse events reported with the collection of and treatment with AS.

AUTHORS' CONCLUSIONS

Overall there was inconsistency in the possible benefits of AS in improving participant-reported symptoms and TBUT and lack of effect based on other objective clinical measures. Well-planned, large, high-quality RCTs are warranted, in different severities of dry eye and using standardized questionnaires to measure participant-reported outcomes and objective clinical tests as well as objective biomarkers to assess the benefit of AS therapy for dry eye.

Effect of topical 0.05% cyclosporine A on corneal endothelium in patients with dry eye disease

AIM

To determine the effect of topical 0.05% cyclosporine A (CsA) on corneal endothelium in patients with dry eye disease.

METHODS

Observational, prospective, case series study. Fifty-five eyes of 29 consecutive patients (9 males and 20 females; median age: 66.8 years, interquartile range: 61-73.2 years) with moderate-severe dry eye disease were evaluated. All patients were treated with topical 0.05% CsA ophthalmic emulsion twice a day in addition to lubricant eyedrops 5 times a day. The follow-up period was 12 months. Before treatment and at 3 and 12 months post-treatment central corneal specular microscopy was performed. The endothelial cell density (ECD), coefficient of variation of cell size (CoV), and percentage of hexagonal cells (Hex %) were analyzed.

RESULTS

The median ECDs pre-treatment and at 3 and 12 months post-treatment were 2 352.5/mm(2) (interquartile range, 2 178-2 548.5), 2364/mm(2) (interquartile range, 2 174.25-2 657.5), and 2366 cells/mm(2) (interquartile range, 2 174.75-2 539.75), respectively (P=0.927, one way ANOVA). The median CoVs pre-treatment and at 3 and 12 months post-treatment were 34.5 (interquartile range, 30-37), 35 (interquartile range, 30-38), and 34 (interquartile range, 30.75-38.25), respectively (P=0.7193, one way ANOVA). The median Hex % values pre-treatment and at 3 and 12 months post-treatment were 53 (interquartile range, 47-58), 54 (interquartile range, 45.75-59), and 50.5 (interquartile range, 45.75-58), respectively (P=0.824, one way ANOVA).

CONCLUSION

Treatment of patients with dry eye disease for 12 months with topical 0.05% CsA does not seem to cause substantial changes on corneal endothelium.

Laser in situ keratomileusis in 2012: a review

Laser in situ keratomileusis (LASIK) is a safe and effective treatment for refractive error. A combination of technological advances and increasing surgeon experience has served to further refine refractive outcomes and reduce complication rates. In this article, we review LASIK as it stands in late 2012: the procedure, indications, technology, complications and refractive outcomes.

Dry eye disease and microbial keratitis: is there a connection?

Dry eye is a common ocular surface disease of multifactorial etiology characterized by elevated tear osmolality and inflammation leading to a disrupted ocular surface. The latter is a risk factor for ocular surface infection, yet overt infection is not commonly seen clinically in the typical dry eye patient. This suggests that important innate mechanisms operate to protect the dry eye from invading pathogens. This article reviews the current literature on epidemiology of ocular surface infection in dry eye patients and laboratory-based studies on innate immune mechanisms operating at the ocular surface and their alterations in human dry eye and animal models. The review highlights current understanding of innate immunity in dry eye and identifies gaps in our knowledge to help direct future studies to further unravel the complexities of dry eye disease and its sequelae.

Correlation between optical coherence tomography-derived assessments of lower tear meniscus parameters and clinical features of dry eye disease

PURPOSE

To measure the correlation between subjective symptom score, conventional clinical tests, and Fourier-domain optical coherence tomography (FD-OCT) of lower tear meniscus parameters in patients with dry eye disease.

METHODS

Eighteen patients with dry eye disease requiring medical therapy and/or punctal occlusion were recruited for this prospective, nonrandomized, observational case series. Severity of symptoms of dry eye disease was assessed using the Indiana University Dry Eye Questionnaire 2002. Clinical assessments were completed using slit-lamp biomicroscopy, rose bengal dye staining, fluorescein tear breakup time (TBUT), and a 5-minute Schirmer test with topical anesthesia. The lower tear meniscus was imaged using an FD-OCT system with 5-μm axial resolution and measured manually by a masked grader using computer calipers. Correlation was assessed using Spearman correlation coefficient (ρ).

RESULTS

The mean (±SD) scaled symptom score was 58 ± 21, with a range of 0 to 100. Vital staining test averaged 1.7 ± 3.4, TBUT averaged 4.4 ± 1.8 seconds, and Schirmer tests averaged 10.2 ± 8.1 mm. As determined by optical coherence tomography, the meniscus height was 228 ± 153 μm, depth was 127 ± 79 μm, and cross-sectional area was 0.018 ± 0.021 mm. Optical coherence tomography meniscus area was negatively correlated with the symptom questionnaire score (P < 0.01) and positively correlated with Schirmer test results (P < 0.01). There was no significant correlation between symptom score and rose bengal staining, TBUT, or Schirmer test results (P > 0.01).

CONCLUSIONS

Lower tear meniscus measurement with FD-OCT is an objective noninvasive test that correlates well with symptoms of dry eye disease and the Schirmer test.

A review on recent advances in dry eye: Pathogenesis and management

Keratoconjunctivitis sicca, more commonly known as dry eye, is an extremely common and often unrecognized disease. It is the condition in ophthalmology that in its mild grade of severity will affect most of the population at one time or other. Due to a wide variety of presentations and symptoms, it often frustrates the ophthalmologists as well as patients. Due to multifactorial and elusive etiology, it is often challenging to treat dry eye. Ocular surface disorders are also clinically important to treat especially in terms of visual acuity. Xero-dacryology is therefore becoming a very important branch of ophthalmology. Recent studies have given insight into the inflammatory etiology of dry eye. The conventional and main approach to the treatment of dry eye is providing lubricating eye drops or tear substitutes. However, the newer treatment approach is to target the underlying cause of dry eye instead of conventional symptomatic relief. In light of the above knowledge, the present article focuses on newer theories on pathogenesis of dry eye and their impact on dry eye management. METHOD OF LITERATURE SEARCH: A systematic literature review was performed using PubMed databases in two steps. The first step was oriented to articles published for dry eye. The second step was focused on the role of inflammation and anti-inflammatory therapy for dry eye. The search strategy was not limited by year of publication. A manual literature search was also undertaken from authentic reference books on ocular surface disease.

The effect of topical cyclosporine A on clinical findings and cytological grade of the disease in patients with dry eye

PURPOSE

To compare the clinical findings and the cytological grade of the disease before and after 6 months of topical cyclosporine A treatment in patients with dry eye.

SETTING

: This single-center prospective study was performed at the Department of Ophthalmology, Ankara University School of Medicine, between January 2007 and June 2008.

METHOD

Forty-five patients with dry eye (with 5 mm/5 minutes or less Schirmer test) were included in the study. Patients were treated with cyclosporine A 0.005% ophthalmic emulsion (RESTASIS) twice daily in addition to lubricant eyedrops 5 times a day. Schirmer test values, tear breakup time (BUT), and impression cytology (goblet cell density, nucleus to cytoplasmic ratio, and epithelial cell morphology) were evaluated at baseline and after 6 months.

RESULTS

Before and after 6 months of the treatment with topical cyclosporine A, the median Schirmer test scores were found as 3.00 and 4.00 mm, respectively. The median BUT score at baseline was 4.00 seconds, and after treatment, the median score was 5.00 seconds. There were statistically significant differences in the median Schirmer and BUT values between, before, and after 6 months of treatment (P < 0.05). The mean cytological grade according to Nelson grading system was 1.84 at baseline and 1.51 after treatment with topical cyclosporine A for 6 months. Statistically significant improvement in cytological grades after treatment was observed (P < 0.05).

CONCLUSION

Treatment of patients with dry eye for 6 months with topical cyclosporine A resulted in an increase in Schirmer test results, an increase in BUT scores, and an improvement in cytological grade of the disease.

A comparison of cyclosporine 0.05% ophthalmic emulsion versus vehicle in Chinese patients with moderate to severe dry eye disease: an eight-week, multicenter, randomized, double-blind, parallel-group trial

PURPOSE

The goals of this study were to compare the efficacy and safety profile of topical cyclosporine 0.05% versus vehicle in Chinese patients with moderate to severe dry eye disease.

METHODS

In this multicenter, randomized, double-blind, vehicle-controlled, parallel-group study, 233 dry eye patients were allocated to receive either cyclosporine 0.05% or vehicle twice daily for 8 weeks. Primary outcome was the difference between groups, in total score of 4 symptoms and 4 signs change from baseline at weeks 2, 4, and 8. Changes in symptoms (ocular dryness, foreign body sensation, photophobia and burning) and signs (conjunctival hyperemia, Schirmer test, tear Break-up time (BUT), and corneal punctate fluorescein staining) at weeks 2, 4, and 8 as well as frequency of administration of concomitant artificial tears, were considered as secondary outcomes. The safety profile was evaluated by examining adverse events, changes in visual acuity, and ocular tolerance.

RESULTS

Greater improvements of the total score were seen in cyclosporine 0.05% group than in the vehicle group at all follow-up times (P < 0.01). Improvements in ocular dryness at week 8 (P = 0.040) and foreign body sensation during weeks 4 and 8 (P < 0.020) were significantly greater with cyclosporine. In addition, compared with the vehicle, cyclosporine significantly improved 2 objective dry eye disease signs: corneal staining at weeks 4 (P = 0.025) and 8 (P = 0.050) and the Schirmer test at week 4 (P = 0.035). However, no between-group difference approached statistical significance in photophobia, burning, BUT value, conjunctival hyperemia and frequency of administration of concomitant artificial tears at any follow-up times (P > 0.05).The cumulative frequency of adverse events did not significantly differ between the groups (P = 0.519), which were 11.21% and 8.55%, respectively. There were no patients who experienced reduced visual acuity.

CONCLUSION

Cyclosporine 0.05% ophthalmic emulsion is an effective and safe treatment for Chinese patients with moderate to severe dry eye disease.

Efficacy in patients with dry eye after treatment with a new lubricant eye drop formulation

PURPOSE

The effective management of dry eye must include a clinically meaningful reduction in ocular staining. Evaluations of corneal and conjunctival staining and other ocular symptoms of dry eye were conducted for a new formulation of polyethylene glycol 400/propylene glycol-based lubricant eye drops containing hydroxypropyl guar as a gelling agent (Test Product) in comparison to Optive Lubricant Eye Drops (Control Product) in adult patients with dry eye.

METHODS

One hundred thirteen patients, 18 years of age and older, with dry eye were enrolled in a prospective, double-masked, multisite, parallel-group study. After a 2-week run-in period during which patients administered aqueous saline eye drops 4 times daily (QID) in each eye, patients were randomized (1:1) to receive either Test Product or Control Product to be administered QID for 6 weeks. Efficacy and safety were evaluated by corneal and conjunctival staining scores, tear film breakup time, assessments of ocular symptoms, ocular surface disease index (OSDI) scores, dry eye treatment satisfaction, visual function-14 questionnaires, and adverse events.

RESULTS

The intent-to-treat data set included 105 patients randomized to Test Product (n = 52) or Control Product (n = 53). Patients primarily were between the ages of 18-64 years (70.5%), female (73.3%), white (93.3%), and not Hispanic (81.9%). Patients in the Test Product group exhibited significantly lower mean corneal staining scores than the Control Product group at day 14 (P = 0.0009) and day 42 (P = 0.0106), and significantly lower mean conjunctival staining scores at day 28 (P = 0.0475) and day 42 (P = 0.0009). Patients in both treatment groups reported significant reductions in the mean scores for the ocular symptoms of dryness, gritty/sandy feeling, and burning (P <or= 0.0021 for all comparisons to baseline). Lastly, a significantly lower OSDI score than baseline was reported at day 42 by patients in both the Test Product (P = 0.0013) and Control Product (P < 0.0001) groups.

CONCLUSIONS

The results of this study indicate that the Test Product significantly reduced corneal and conjunctival staining, indicating a reduction in disease severity. Evaluations of ocular staining scores provide clinically meaningful evidence of dry eye severity and are an important indicator of dry eye disease progression.

Novel hydroxypropyl-guar gellable lubricant eye drops for treatment of dry eye

OBJECTIVE|: The objective of this review is to evaluate the safety and efficacy of polyethylene glycol 400/propylene glycol/hydroxypropyl-guar (Systane® Ultra [PEG/PG with HP-guar], Alcon Laboratories, Inc., Fort Worth, TX, USA) lubricant eye drops in reducing the signs and symptoms of dry-eye disease. METHODS|: A systematic literature search utilizing MEDLINE was conducted to identify peer-reviewed articles related to dry-eye disease and PEG/PG with HP-guar lubricant eye drops. The search covered the period prior to October 2009. Additionally, a manual search based on citations in the published literature was conducted. RESULTS|: The PEG/PG with HP-guar artificial tears shows in-vitro viscoelastic properties with pH optimization. The pH of the solution adjusts to the pH of the ocular surface upon instillation, which results in tear film elasticity and viscosity similar to that of subjects without dry-eye disease. The reviewed literature demonstrated that this delivery system showed a reduction in corneal and conjunctival staining in dryeye disease, an improvement in tear film stability, a low coefficient of friction in an in-vitro model, and improved maintenance of best-corrected visual acuity over time. CONCLUSION|: A few small-sized studies with short-term follow-up demonstrated that PEG/PG with HP-guar is a safe and effective lubricant eye drops for the treatment of dry-eye disease. Larger studies with longer duration are warranted to assess the long-term safety and efficacy of this formulation in patients with dry.eye disease.