Agreement of Physician Treatment Practices With the International Task Force Guidelines for Diagnosis and Treatment of Dry Eye Disease

Comparison of therapeutic effects of 0.05% Cyclosporine A versus 0.1% Fluorometholone in Chinese patients with mild dry eye unresponsive to artificial tears: a randomized control study

BACKGROUND

To assess and compare the therapeutic outcomes of 0.05% Cyclosporine A (CsA) ophthalmic solution versus 0.1% Fluorometholone (FML) eyedrops in Chinese patients with mild dry eye disease (DED) unresponsive to conventional artificial tears (AT).

METHODS

A total of 43 patients with mild DED, who have failed to respond to conventional AT therapy for over 3 months, were randomly assigned to receive either 0.05% CsA or 0.1% FML twice daily for 6-months. In addition, all the patients were instructed to use 0.1% SH 4 times a day as supplementary therapy. Dry eye examination, including Ocular Surface Disease Index (OSDI) questionnaire, non-invasive tear break-up time (NIBUT), Schirmer scores, corneal fluorescein staining (CFS) scores, and conjunctival goblet cell (CGC) density, intraocular pressure (IOP), Best corrected visual acuity (BCVA) was conducted at baseline and then evaluated at 1, 3, and 6 months after treatment. Corneal endothelial cell density, corneal dendritic cells (DCs) and nerves were assessed by in vivo confocal microscopy at baseline and 6 months after treatment.

RESULTS

At 3 and 6 months after treatment, OSDI scores in the 0.05% CsA group showed more improvement than those in the 0.1% FML group. CFS was significantly lower and Schirmer scores were significantly higher in 0.05% CsA group compared with 0.1% FML group. NIBUT improved significantly in both groups, with greater improvement in the 0.05% CsA group at the 1-, 3-, and 6-month visits. Throughout the duration of the study, the 0.1% FML group exhibited no notable enhancement in CGC density. Conversely, a substantial elevation in CGC density was observed in the 0.05% CsA group. After 6 months of treatment, significantly reduced corneal DC density and area were obtained in 0.05% CsA group as compared to 0.1% FML group, while there were no significant changes in cornea nerve fiber density, cornea nerve fiber length and cornea nerve fiber width in both groups. Additionally, after 6 months of treatment, neither group showed any statistically significant changes in IOP, BCVA or in corneal endothelial cell density.

CONCLUSION

The administration of 0.05% CsA proved effective in managing mild DED, offering a supplementary advantage in improving Schirmer scores, restoring CGC density and reducing corneal DC density compared to 0.1% FML eyedrops. Consequently, 0.05% CsA eyedrops are recommended as a safe and efficacious therapeutic alternative for patients with mild DED who fail to respond to conventional tear substitutes therapy.

CLINICAL TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2200066441, Registered 06 December 2022-Retrospectively registered.

Bilateral Increase of the Matrix Metalloproteinase-9 Expression in Tears After the Unilateral Decrease of Corneal Sensitivity

PURPOSE

The purpose of this study is to analyze bilateral changes of matrix metalloproteinase-9 (MMP-9) expression in the tear film in patients with unilateral neurotrophic keratitis.

METHODS

We included 24 eyes from 24 subjects with normal corneal sensitivity according to Cochet-Bonnet corneal esthesiometry in the control group and 25 subjects with the unilateral neurotrophic keratitis in the unilateral decrease of corneal sensitivity (UDCS) group. The expression of MMP-9 in tears was assessed using point-of-care immunoassay. The clinical parameters including meibomian gland plugging, quality of the secreted meibum, tear secretion using Schirmer I without anesthesia, and corneal erosions were evaluated among the control, affected, and contralateral unaffected eyes in the UDCS group.

RESULTS

Tear MMP-9 grades in affected (2.5 ± 1.0) and contralateral eyes (2.6 ± 0.9) in the UDCS group were higher than those in control eyes (1.5 ± 0.7, P = 0.0003 and P = 0.0006, respectively). The lacrimal secretion decreased in the affected eyes but preserved in the contralateral eyes. There was no difference in corneal erosion scores between control eyes and contralateral eyes in the UDCS group. Tear MMP-9 grades in the contralateral eyes were significantly correlated with the meibum quality grades in the contralateral eyes (r = 0.525 and P = 0.025).

CONCLUSIONS

Patients with the unilateral neurotrophic keratitis demonstrated a significant bilateral increase of the MMP-9 expression in the tear film as compared with controls. Despite the tearing reflex and corneal surface barrier being preserved in the unaffected contralateral eyes, it is necessary to pay attention to the possible attenuation of meibomian gland function in the opposite eyes as well.

Correlation Analysis between Ocular Surface Parameters with Subjective Symptom Severity in Dry Eye Disease

Purpose

To evaluate the clinical symptoms of patients with dry eyes, based on the ocular surface disease index (OSDI) and analyze the relationship between OSDI and various ocular surface parameters.

Methods

This was a retrospective study that included 45 eyes of 45 dry eye patients who visited the Seoul Nune Eye Hospital from August 2017 to December 2017. The patients were assessed by non-invasive keratography for the first break-up time, lipid layer thickness (LLT), tear osmolarity, tear matrix metalloproteinase-9 immunoassay as well as with the conventional Schirmer I test and fluorescein break-up time. The patient's symptoms were evaluated by the OSDI questionnaires and correlations were analyzed based on the parameters described above.

Results

There were significant negative correlations between OSDI and non-invasive keratography for the first break-up time (p = 0.038, r = −0.330), and LLT (p = 0.005, r = −0.426). However, there were no significant correlations between OSDI and fluorescein break-up time, Schirmer I score, and tear osmolarity (p = 0.173, 0.575, and 0.844 respectively). OSDI was not significantly different between matrix metalloproteinase-9 positive and negative groups (p = 0.768).

Conclusions

Non-invasive examinations such as non-invasive keratograph break-up time and interferometry of LLT can be efficient tools for evaluating dry eye symptoms.

Videographic Analysis of Blink Dynamics following Upper Eyelid Blepharoplasty and Its Association with Dry Eye

This study was undertaken to characterize the effects of upper eyelid blepharoplasty on blink dynamics and to evaluate the hypothesis that changes in blink dynamics following blepharoplasty are associated with postoperative dry eye.

Dry eye symptoms and impact on vision-related function across International Task Force guidelines severity levels in the United States

BACKGROUND

International Task Force (ITF) guidelines established a grading scheme to support treatment of dry eye disease based on clinical signs and symptoms. The purpose of this study was to assess the impact of dry eye on vision-related function across ITF severity levels using the Ocular Surface Disease Index (OSDI) questionnaire.

METHODS

Non-interventional, cross-sectional study of prescription treatment-naïve dry eye patients seeking symptom relief at 10 ophthalmology and optometry practices. Clinicians assessed corneal and conjunctival staining, tear break-up time, Schirmer's test (type I with anesthesia), and best-corrected visual acuity. Patients completed the OSDI questionnaire and OSDI overall and domain (Symptoms, Visual Function, and Environmental Triggers) scores were compared across ITF guidelines severity levels (1-4).

RESULTS

Of 158 patients (mean age, 55 years) enrolled, 52 (33%) were ITF level 1, 54 (34%) ITF level 2, and 52 (33%) ITF levels 3/4 combined. No significant differences were observed in most baseline characteristics. Overall OSDI scores (mean [standard deviation]) were 26.5 [20.0] for ITF level 1, 33.8 [17.5] for ITF level 2, and 44.9 [26.1] for ITF level 3/4 cohorts (P < 0.0001). Component OSDI Symptoms, Visual Function, and Environmental Triggers domain scores all worsened with increasing ITF severity level (P ≤ 0.01).

CONCLUSIONS

Dry eye disease has significant deleterious impact on vision-related function across all ITF severity levels.

Epidemiology of dry eye disease in Africa: The sparse information, gaps and opportunities

Dry eye disease (DED) is an increasingly significant clinical problem in developing countries and/or emerging economies. Existing studies on DED conducted in these areas have largely reported on associations between DED and infectious disease (trachoma) and malnutrition (hypovitaminosis A), but current trends of industrialization, urbanization, and modernization in these areas could result in a shift to other forms of DED. Herein, we review the epidemiology of DED in these geographic areas, highlighting potential causes and risk factors of DED while presenting information on diagnostic tools and algorithms and insight into some treatment modalities of DED that could prove useful to clinicians and investigators in these regions.

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.

Efficacy and Safety of Topical 0.05% Cyclosporine Eye Drops in the Treatment of Dry Eye Syndrome: A Systematic Review and Meta-analysis

A systematic review was performed to evaluate the safety and efficacy of topical 0.05% cyclosporine in treating patients with dry eye syndrome (DES). Twelve qualified randomized-controlled trials incorporating 1367 patients were analyzed. In comparison to controls, patients who were on topical 0.05% cyclosporine eye drops had lower Ocular Surface Disease Index scores (mean difference [MD]=4.10, 95% CI: 0.25-7.96, P=.04), longer tear film breakup time (MD=2.30 seconds, 95% CI: 0.75-3.86, P=.004), improved Schirmer I scores (MD=2.77 mm/5min, 95% CI: 1.63-3.91, P=.00001), reduced corneal fluorescein staining (standardized mean difference [SMD]=0.61, 95% CI: 0.07-1.15, P=.03), and higher goblet cell densities (SMD=1.68, 95% CI: 0.54-2.81, P=.004). However, there were more adverse effects in the cyclosporine patient group (odds ratio=1.64, 95% CI: 1.17-2.30, P=.004). Topical 0.05% cyclosporine eye drops twice daily significantly improved both the objective and subjective outcomes in DES patients. The study limitations in the clinical, methodological and statistical heterogeneities are discussed.

Artificial tears potpourri: a literature review

Numerous brands and types of artificial tears are available on the market for the treatment of dysfunctional tear syndrome. Past literature has focused on comparing the components of these products on patient’s clinical improvement. The wide array of products on the market presents challenges to both clinicians and patients when trying to choose between available tear replacement therapies. Different formulations affect patients based on etiology and severity of disease. In order to provide an unbiased comparison between available tear replacement therapies, we conducted a literature review of existing studies and National Institutes of Health clinical trials on commercially available, brand name artificial tears. Outcomes evaluated in each study, as well as the percent of patients showing clinical and symptomatic improvement, were analyzed. Fifty-one studies evaluating different brands of artificial tears, and their efficacy were identified. Out of the 51 studies, 18 were comparison studies testing brand name artificial tears directly against each other. Nearly all formulations of artificial tears provided significant benefit to patients with dysfunctional tear syndrome, but some proved superior to others. From the study data, a recommended treatment flowchart was derived.

Korean guidelines for the diagnosis and management of dry eye: development and validation of clinical efficacy

Purpose

To evaluate the clinical efficacy of newly developed guidelines for the diagnosis and management of dry eye.

Methods

This retrospective, multi-center, non-randomized, observational study included a total of 1,612 patients with dry eye disease who initially visited the clinics from March 2010 to August 2010. Korean guidelines for the diagnosis and management of dry eye were newly developed from concise, expert-consensus recommendations. Severity levels at initial and final visits were determined using the guidelines in patients with 90 ± 7 days of follow-up visits (n = 526). Groups with different clinical outcomes were compared with respect to clinical parameters, treatment modalities, and guideline compliance. Main outcome measures were ocular and visual symptoms, ocular surface disease index, global assessment by patient and physician, tear film break-up time, Schirmer-1 test score, ocular surface staining score at initial and final visits, clinical outcome after three months of treatment, and guideline compliance.

Results

Severity level was reduced in 47.37% of patients treated as recommended by the guidelines. Younger age (odd ratio [OR], 0.984; p = 0.044), higher severity level at initial visit, compliance to treatment recommendation (OR, 1.832; p = 0.047), and use of topical cyclosporine (OR, 1.838; p = 0.011) were significantly associated with improved clinical outcomes.

Conclusions

Korean guidelines for the diagnosis and management of dry eye can be used as a valid and effective tool for the treatment of dry eye disease.

Current practice pattern for dry eye patients in South Korea: a multicenter study

Purpose

To assess current practice patterns for dry eye patients in South Korea and to evaluate the preference according to the ages and clinic types of physicians.

Methods

Dry eye patients (n = 1,612) were enrolled in this multicenter cross-sectional, observational study. The severity level of dry eye patients was classified based on the Korean guidelines for dry eye treatment. The medical records of the enrolled dry eye patients were evaluated, and the practice styles and the preferences were analyzed according to the ages and clinic types of physicians.

Results

Of all patients, dry eye level 1 was most common (47.5%), followed by level 2 (33.5%), level 3 (9.1%), and level 4 (1.1%). Topical anti-inflammatory agents were used in 70.7% of patients with dry eye level 2 and in 80.6% of patients at levels 3 and 4. Topical anti-inflammatory agents were also used in 48.7% of patients with dry eye level 1. Preservative-free artificial tears were preferred at all dry eye levels. The use of topical anti-inflammatory agents did not differ with investigator ages, but older physicians preferred preserved artificial tears more than younger ones. Physicians at referral hospitals also tended to use topical anti-inflammatory agents and preservative-free artificial tears earlier, beginning at dry eye level 1, than those who worked at private eye clinics.

Conclusions

Topical anti-inflammatory agents were commonly prescribed for the treatment of dry eye patients in South Korea, even from dry eye level 1. Preservative-free artificial tears were preferred at all dry eye levels. Practice styles differed somewhat depending on the ages and clinic types of physicians.

PERSIST: Physician's Evaluation of Restasis(®) Satisfaction in Second Trial of topical cyclosporine ophthalmic emulsion 0.05% for dry eye: a retrospective review

Background

Chronic dry eye disease often requires long-term therapy. Tear film alterations in the setting of dry eye may include reduced tear volume as well as an increase in inflammatory cytokines and osmolarity. Topical cyclosporine ophthalmic emulsion 0.05% (Restasis^®; Allergan Inc, Irvine, CA) is indicated to increase tear production in patients with dry eye and reduced tear production presumed to be due to ocular inflammation. This study was designed to evaluate the efficacy of a second trial of topical cyclosporine in patients with dry eye who were previously considered treatment failures.

Materials and methods

This multicenter (three cornea practices) retrospective chart review evaluated clinical outcomes in patients with dry eye who received a second trial of cyclosporine after a prior treatment failure, defined as prior discontinuation of topical cyclosporine after less than 12 weeks.

Results

Thirty-five patients, most of whom were female (71.4%) and Caucasian (62.9%), were identified. Prior discontinuation was most commonly due to burning/stinging (60%). The median duration of second treatment was 10 months (range 1 week to 45 months). Physician education was provided in the second trial in 97.1% of cases. At initiation of the second trial of cyclosporine, 10 (28.6%) patients received courses of topical corticosteroids. Physicians reported on a questionnaire that 80% of patients achieved clinical benefit with a second trial of cyclosporine.

Conclusion

A repeat trial with topical cyclosporine can achieve clinical success. Direct patient education via the physician and staff may be key to success. Proper patient education may overcome adherence issues, particularly with respect to the need for long-term treatment of chronic dry eye. This study has the usual limitations associated with a retrospective chart review, and future prospective studies are warranted.

Evaluation of dry eye signs and symptoms in patients with systemic sclerosis

BACKGROUND

One of the most frequent ocular features of systemic sclerosis (SSc) is dry eye disease (DED), which has been identified to occur in 37-79% of patients. Although several studies have found weak or no correlations between symptoms and signs of dry eye, symptoms are often the motivation for seeking eye care, and are therefore a critical outcome measure when assessing treatment effect. The aim of this study is to evaluate the impact of symptoms of dry eye on vision-related quality of life in patients with systemic sclerosis, and to investigate the relation between clinical tests and symptoms of dry eye in these patients.

METHODS

In this cross-sectional study, 45 consecutive patients with SSc were enrolled. For evaluation of the symptoms the "Ocular Surface Disease Index (OSDI)" questionnaire was applied to all patients. After that, all individuals were submitted to a full ophthalmic examination, including the following tests: tear break-up time, Schirmer I, rose bengal staining. Patients were then grouped into dry eye and non-dry eye groups with regard to the diagnosis of dry eye. Mann-Whitney test was used to compare continuous variables, whereas the Fisher exact test was used to compare categorical data between groups. Spearman's correlation test was used to analyze the correlations between clinical tests and OSDI scores. P values <0.05 were considered significant.

RESULTS

Dry eye disease was diagnosed in 22 patients (48.9%). Other ocular surface abnormalities found were: blepharitis (40% of the patients), pterygium (15.6%), pinguecula (82.2%), and superficial punctate keratitis (26.7%). Among the 45 patients, 29 patients (64.4%) had symptoms of ocular surface disease. The mean OSDI score was 26.8 ± 25.8 (SD). There were no statistically significant differences in OSDI scores between DED and non-DED patients. No substantive correlations were found between OSDI scores and TBUT, Schirmer I, or rose bengal staining score, and none of the observed correlations reached statistical significance.

CONCLUSION

Symptoms of dry eye have a moderate impact on vision-related quality of life in patients with systemic sclerosis and do not correlate well with clinical findings.

Reversibility of dry eye deceleration after topical cyclosporine 0.05% withdrawal

PURPOSE

To assess the reversibility of clinical benefits of cyclosporine 0.05% (Restasis(®); Allergan, Inc., Irvine, CA) therapy and the therapeutic gain after its delayed use by switching treatment modalities in patients with dry eyes who completed a 1-year course of therapy with artificial tears (Refresh Endura(®); Allergan, Inc., Irvine, CA) or cyclosporine 0.05%.

METHODS

This was a single-center, prospective, investigator-masked, longitudinal extension trial. Patients who had been treated with cyclosporine 0.05% in the first year of study were randomized in a 2:1 ratio to either cyclosporine 0.05% (Cs-Cs; n=20) or artificial tears (Cs-At; n=8), and those who had been originally randomized to artificial tears were switched to cyclosporine 0.05% (At-Cs; n=20) in the second year of study. Patients received study drugs twice daily for 12 months. Disease severity was assessed according to the International Task Force consensus guideline at months 0 and 12. Signs and symptoms were evaluated at baseline (month 0) and months 4, 8, and 12.

RESULTS

At baseline, most patients with Cs-Cs and Cs-At (>90%) had level 2 disease severity, whereas almost half of the patients with At-Cs had level 3 disease severity. At month 12, a significantly higher percentage of patients with Cs-Cs and At-Cs than patients with Cs-At had the same or lower disease severity (P<0.001); whereas half of patients with Cs-At, compared with patients with no Cs-Cs and At-Cs, had disease progression at month 12. Throughout the study, dry eye signs and symptoms continuously improved in patients with Cs-Cs and At-Cs, whereas they constantly worsened in patients with Cs-At. At month 12, patients with Cs-Cs and At-Cs had significantly greater mean percentage improvement from baseline than did patients with Cs-At in Schirmer test scores, tear breakup time, Oxford staining scores, Ocular Surface Disease Index scores, and conjunctival goblet cell density (P<0.001). Overall, sign and symptom scores of patients with At-Cs did not improve as much as they did for patients with Cs-Cs.

CONCLUSIONS

Cyclosporine 0.05% withdrawal led to disease progression, thus indicating the necessity for maintenance therapy. Earlier treatment with cyclosporine 0.05% may result in improved outcomes.

MMP-9 and the perioperative management of LASIK surgery

PURPOSE OF REVIEW

Hyperosmolarity is a central mechanism causing ocular surface inflammation and eye irritation in typical patients suffering from tear dysfunction. Tear composition in dry eyes, or dysfunctional tear syndrome, may destabilize the tear film and cause ocular surface epithelial disease. Increased activity of matrix metalloproteinases (MMPs), especially MMP-9, plays a critical role in wound healing and inflammation and is primarily responsible for the pathologic alterations to the ocular surface that leads to a dysfunctional tear state.

RECENT FINDINGS

Altered corneal epithelial barrier function is the cause for ocular irritation and visual morbidity in dry eye disease. The increased MMP-9 activity in dry eyes may contribute to deranged corneal epithelial barrier function, increased corneal epithelial desquamation, and corneal surface irregularity.

SUMMARY

Dry eye is one of the most common complications of photorefractive keratectomy and laser in-situ keratomileusis (LASIK). LASIK has both a neurotrophic effect on the cornea and leads to a physical change in corneal shape that results in a change in tear dynamics, leading to ocular surface desiccation. The reduction in tear function after LASIK may induce an increase in osmolarity and consequently raise the concentration of proinflammatory cytokines and MMP-9 in the tear film, which results in dry eyes and insufficient attachment between the corneal flap and the corneal bed. Appropriate diagnosis and management of dysfunctional tear syndrome may lead to less postoperative LASIK complications.

The economic burden of dry eye disease in the United States: a decision tree analysis

PURPOSE

The aim of this study was to estimate both the direct and indirect annual cost of managing dry eye disease (DED) in the United States from a societal and a payer's perspective.

METHODS

A decision analytic model was developed to estimate the annual cost for managing a cohort of patients with dry eye with differing severity of symptoms and treatment. The direct costs included ocular lubricants, cyclosporine, punctal plugs, physician visits, and nutritional supplements. The indirect costs were measured as the productivity loss because of absenteeism and presenteeism. The model was populated with data that were obtained from surveys that were completed by dry eye sufferers who were recruited from online databases. Sensitivity analyses were employed to evaluate the impact of changes in parameters on the estimation of costs. All costs were converted to 2008 US dollars.

RESULTS

Survey data were collected from 2171 respondents with DED. Our analysis indicated that the average annual cost of managing a patient with dry eye at $783 (variation, $757-$809) from the payers' perspective. When adjusted to the prevalence of DED nationwide, the overall burden of DED for the US healthcare system would be $3.84 billion. From a societal perspective, the average cost of managing DED was estimated to be $11,302 per patient and $55.4 billion to the US society overall.

CONCLUSIONS

DED poses a substantial economic burden on the payer and on the society. These findings may provide valuable information for health plans or employers regarding budget estimation.

[Diagnostics of dry eye]

INTRODUCTION

Dry eye is a multi-factorial disease of tears and ocular surface resulting in symptoms of discomforts, vision disabilities, unstable tear film and possible damage to the ocular surface. The final diagnosis of dry eye results from collecting various data obtained in the course of several diagnostic procedures. DRY EYE - DIAGNOSTIC METHODS: Diagnosis of dry eye involves performing a series of clinical methods and laboratory tests. This paper presents some of the procedures used in the diagnosis of dry eye. Biomicroscopy of the eye with objective tests to check the tear film (Schirmer I, rose bengal, time break up precorneal tear film), verification of corneal sensitivity and impression cytology of the conjunctiva, are the optimum dry eye diagnostic routine procedures.

CONCLUSION

The combination of clinical and histopathological methods of examination of the anterior ocular surface is the basis for a quality and precise diagnosis of dry eye.

Topical cyclosporine 0.05% for the prevention of dry eye disease progression

PURPOSE

To assess the prognosis of dry eye in patients treated with cyclosporine 0.05% or artificial tears by using the International Task Force (ITF) guidelines.

METHODS

This was a single-center, investigator-masked, prospective, randomized, longitudinal trial. Dry eye patients received twice-daily treatment with either cyclosporine 0.05% (Restasis; Allergan, Inc., Irvine, CA; n = 36) or artificial tears (Refresh Endura; Allergan, Inc., Irvine, CA; n = 22) for 12 months. Disease severity was determined at baseline and month 12 according to the consensus guidelines developed by the ITF. Dry eye signs and symptoms were evaluated at baseline and months 4, 8, and 12.

RESULTS

Baseline sign and symptom scores and the proportion of patients with the disease severity level 2 or 3 were comparable in both groups (P > 0.05). At month 12, 34 of 36 cyclosporine patients (94%) and 15 of 22 artificial tear patients (68%) experienced improvements or no change in their disease severity (P = 0.007) while 2 of 36 cyclosporine patients (6%) and 7 of 22 artificial tears patients (32%) had disease progression (P < 0.01). Cyclosporine 0.05% improved Schirmer test scores, tear breakup time, and Ocular Surface Disease Index scores throughout the study, with significant (P < 0.01) differences compared with artificial tears being observed at months 8 and 12.

CONCLUSIONS

Treatment with cyclosporine 0.05% may slow or prevent disease progression in patients with dry eye at severity levels 2 or 3.

Impact of dry eye disease and treatment on quality of life

PURPOSE OF REVIEW

Recent increased awareness of dry eye disease (DED) by both clinicians and patients has been accompanied by improved recognition that it is a chronic disorder often requiring long-term management. DED, frequently associated with symptoms of discomfort and visual disturbance, also impairs quality of life (QoL), including aspects of physical, social, and psychological functioning. This review summarizes the available research on the impact of DED and its treatment on measures of QoL.

RECENT FINDINGS

A relative dearth of data supporting the effectiveness of DED treatments as assessed by QoL measures exists. Both cyclosporine ophthalmic emulsion 0.05% and hydroxypropyl cellulose ophthalmic inserts have been associated with improvements in Ocular Surface Disease Index scores, a disease-specific measure of QoL, and with enhancement of patients' ratings regarding their ability to perform activities of daily living.

SUMMARY

Because there is a lack of concordance between symptoms and diagnostic measures of DED, QoL measures provide clinicians a valuable tool for assessing the burden of disease as well as response to treatment. Such measures should be employed in clinical practice and in future trials of treatment modalities.

Therapeutical approach to dry eye syndrome

Introduction. Dry eye disease or dysfunctional tear syndrome is among the most frequently established diagnoses in ophthalmology. It can be defined as a disorder of the tear film resulting in changes in the ocular surface. Mechanisms in development of dry eye disease. There are many factors causing dry eye and they can be related to deficiency in any of the components of the tear film. It has been suggested that dry eye is an inflammatory disorder that affects the ocular surface and lacrimal gland. Inflammation is the most important mechanism of corneal and conjunctival cell damage, which is responsible for the symptoms and signs of ocular surface pathology. Hormonal imbalance (particularly androgens), neural dysfunction, increased levels of pro-inflammatory cytokines and loss of immune homeostasis of the lacrimal gland and ocular surface could be possible mechanisms in the pathogenesis of dry eye disease. Discussion. The aim of this paper was to review the advances in the pathogenesis and management of the dry eye disease. The appropriate dry eye treatment presupposes knowledge of all existing pharmacologic and non-pharmacologic therapeutic modalities. The mainstay of therapy is still artificial tears, with anti-inflammatory therapy and punctual occlusion therapy as second and third line therapies.

Management of dysfunctional tear syndrome: a Canadian consensus

Dry eye complaints are common, have a diverse etiology, and result from disruption of the normal tear film; hence, the term "dysfunctional tear syndrome." Recent research has shown that ocular surface disorders have an inflammatory origin, that inflammation of the ocular surface does not always manifest as "red eye," and that a patient does not have to have a systemic autoimmune disease to experience a local, ocular autoimmune event. A panel of Canadian cornea and external disease subspecialists met and developed a questionnaire and treatment algorithm to aid the comprehensive ophthalmologist. Management of ocular surface disorders begins with a review of the patient's medical history, with particular attention to medication use, and a thorough ophthalmological examination. Use of a simple questionnaire can aid in the diagnosis. A variety of treatment modalities are available, the most effective of which are those that target the underlying inflammatory process with the goal of restoring the normal tear film. A treatment algorithm is presented that matches the severity of symptoms with the intensity of treatment. Lifestyle modifications, regular hygiene, and tear supplements may be sufficient in patients with mild symptoms. Anti-inflammatory medications (topical cyclosporin A, short courses of topical steroids, and [or] oral tetracyclines) and physical measures (punctal plugs, moisture-retaining eye wear) are implemented for those with moderate-to-severe symptoms. Autologous serum tears, scleral contact lenses, and surgery are reserved for patients with severe symptoms who have an unsatisfactory response to anti-inflammatory medications. Patients with lid disease or rosacea and those with allergic conditions should be identified during the initial encounter and should receive specific therapy to relieve their symptoms.

Preliminary effects of oral uridine on the ocular surface in dry eye patients

We designed a randomized, double blinded, 3-months controlled prospective clinical study to investigate effects of oral uridine on the ocular surface in dry eye patients. Twenty-seven patients who diagnosed as dry eye with lower than 5 mm of wetting in the Schirmer strip, with corneal epithelial erosion and who completely followed-up till 3 months were enrolled. Corneal-conjunctival fluorescein staining, non-anesthetic Schirmer test, impression cytology, and Ocular Surface Disease Index (OSDI) were evaluated in the experimental and placebo groups at the baseline, 1 and 3 months after start of medication in a double blinded manner. Fluorescein stain score of the cornea was markedly decreased in oral uridine group compared to the placebo group at 3 months after medication (P=0.032, Mann-Whitney U test). The Schirmer wetting score for the oral uridine group was significantly increased (P=0.001, Wilcoxon signed rank test) at 3 months and its difference between two groups was statistically significant (P=0.030, Mann-Whitney U test). OSDI scores were significantly decreased at 1 and 3 months in treatment group. Oral uridine is effective in treatment of dry eyes.