Video display terminal use and dry eye: preventive measures and future perspectives

Blue light induced ferroptosis via STAT3/GPX4/SLC7A11/FTH1 in conjunctiva epithelium in vivo and in vitro

The prevalence of Light-emitting diodes (LEDs) has exposed us to an excessive amount of blue light (BL) which causes various ophthalmic diseases. Previous studies have shown that conjunctiva is vulnerable to BL. In this study, we aimed to investigate the underlying mechanism of BL-induced injury in conjunctiva. We placed C57BL/6 mice and human conjunctival epithelial cell lines (HCECs) under BL (440 nm ± 15 nm, 0.2 mW/cm2) to establish a BL injury model in vivo and in vitro. Immunohistochemistry and MDA assay were used to identify lipid peroxidation (LPO) in vivo. HE staining was applied to detect morphological damage of conjunctival epithelium. DCFH-DA, C11-BODIPY 581/591, Calcein-AM, and FeRhoNox™-1 probes were performed to identify ferroptosis levels in vitro. Real-time qPCR and Western blotting techniques were employed to uncover signaling pathways of blue light-induced ferroptosis. Our findings demonstrated that BL affected tear film instability and induced conjunctival epithelium injury in vivo. Ferrostatin-1 significantly alleviated blue light-induced ferroptosis in vivo and in vitro. BL downregulates the levels of solute carrier family 7 member 11 (SLC7A11), Ferritin heavy chain (FTH1), and glutathione peroxidase (GPX4) by inhibiting the activation and translocation of the Signal transducer and activator of transcription 3 (STAT3) from inducing Fe2+ burst, ROS and LPO accumulation, ultimately resulting in ferroptosis. This study will offer new insight into BL-induced conjunctival injury and LED-induced dry eye.

Clinical Efficacy of 2% Rebamipide in Patients With Video Display Terminal-Associated Dry Eye Disease: A Prospective, Randomized, Double-Blinded Study

PURPOSE

To compare the effects of 2% rebamipide clear solution and 0.1% sodium hyaluronate eye drops in patients with visual display terminal (VDT)-related dry eye disease (DED).

DESIGN

Prospective, randomized, double-blinded Study.

METHODS

This was a prospective, double-blind, and randomized controlled study. Patients with VDT-related DED were randomly allocated to a 2% rebamipide (REB) group or a 0.1% sodium hyaluronate (HYA) group (4 times/day for 4 weeks). The ocular surface disease index (OSDI), dry eye questionnaire-5 (DEQ-5), Placido disk-tear film analyzer, fluorescein-stained tear break-up time (FBUT), ocular surface staining score, and Schirmer 1 test were examined before and after the instillation of drug.

RESULTS

A total of 56 eyes of 28 patients (28 eyes of 14 patients in each group) were included. There were no significant differences in the baseline data. The OSDI, DEQ-5, FBUT, and conjunctival erosion scores improved significantly in both groups after treatment. In the REB group, corneal staining and bulbar nasal redness scores also improved significantly after treatment (P<0.001 and 0.036, respectively), whereas no significant differences were found in these parameters in the HYA group (P=0.326 and 0.118, respectively). The REB group showed a significantly larger decrease in the corneal staining score than the HYA group (P=0.016). No adverse reactions were observed.

CONCLUSIONS

A 2% rebamipide clear solution effectively improved the symptoms and signs in patients with VDT-related DED and was superior to 0.1% sodium hyaluronate ophthalmic solution in improving corneal epithelial damage, making it a safe and effective treatment option for VDT-related DED.

Mitochondrial DNA-Activated cGAS-STING Signaling in Environmental Dry Eye

Purpose

The cGAS-STING pathway has been shown to be an important mediator of inflammation. There is emerging evidence of the importance of this signaling cascade in a variety of inflammatory diseases settings. Here, we present evidence that the mitochondrial DNA (mtDNA) damage-mediated cGAS-STING pathway plays an important role in the induction of inflammation in environmental dry eye (DE).

Methods

RT-qPCR and Western blot were used to assess the induction of the cGAS-STING pathway and inflammatory cytokines in environmental DE mouse model, primary human corneal epithelial cells (pHCECs), and patients with DE. RNA sequencing was used to determine mRNA expression patterns of high osmotic pressure (HOP)-stimulated pHCECs. mtDNA was detected with electron microscopy, flow cytometry, and immunofluorescent staining. mtDNA was isolated and transfected into pHCECs for evaluating the activation of the cGAS-STING pathway.

Results

The expression levels of cGAS, STING, TBK1, IRF3, and IFNβ were significantly increased in an environmental DE model and HOP-stimulated pHCECs. The STING inhibitor decreased the expression of inflammatory factors in DE. An upregulation of STING-mediated immune responses and IRF3 expression mediated by TBK1 were observed in the HOP group. HOP stimulation induced mitochondrial oxidative damage and the leakage of mtDNA into the cytoplasm. Then, mtDNA activated the cGAS-STING pathway and induced intracytoplasmic STING translocated to the Golgi apparatus. Finally, we also found activated cGAS-STING signaling in the human conjunctival blot cell of patients with DE.

Conclusions

Our findings suggest that the cGAS-STING pathway is activated by recognizing cytoplasmic mtDNA leading to STING translocation, further exacerbating the development of inflammation in environmental DE.

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

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

New advances in medical management of dry eye: optimizing treatment strategies for enhanced relief

PURPOSE

Dry eye disease (DED) is a prevalent ocular surface disease that is conventionally characterized by tear film hyperosmolarity and instability. This review presents a summarized classification of DED, followed by a comprehensive discussion of the most recent topical and systemic medications and clinical recommendations for selecting the most appropriate option for each patient.

METHODS

An extensive literature search was conducted on electronic databases, such as PubMed, Scopus, and Web of Science, using keywords including "dry eye syndrome," "ocular surface disease," "medical management," "artificial tears," "topical immunomodulators," and "meibomian gland dysfunction."

RESULTS

The underlying reasons for DED can range from insufficient aqueous tear production to increased tear evaporation. Recent literature has provided a more in-depth understanding of the pathophysiology of DED by examining the tear film's lipid, aqueous, and mucin layers. However, despite these advancements, medical management of patients with symptomatic DED has not fully reflected this modernized knowledge of its pathophysiology.

CONCLUSION

To develop a rationalized strategy for treating DED, it is crucial to have updated knowledge of therapeutic options, their mechanisms of actions, and indications based on the DED type and underlying causes.

Enhancing Ocular Surface in Dry Eye Disease Patients: A Clinical Evaluation of a Topical Formulation Containing Sesquiterpene Lactone Helenalin

The aim of this work was to assess the tolerability, safety, and efficacy of an ophthalmic topical formulation containing helenalin from Arnica montana and hyaluronic acid 0.4% (HA) in patients with mild-to-moderate Dry Eye Disease (DED) exhibiting positive Matrix Metalloproteinase 9 (MMP-9) test results. Tolerability and safety were evaluated in 24 healthy subjects. Participants were instructed to apply one drop of the formulation three times a day in the study eye, for 2 weeks, followed by a clinical follow-up of 21 days. Efficacy was studied in 48 DED patients randomized into Study (Group 1/receiving the studied formulation) or Control (Group 2/Receiving HA 0.4% eye lubricant) groups for 1 month. Assessments included an MMP-9 positivity test, conjunctival impression cytology (CIC), Ocular Surface Disease Index (OSDI), non-invasive film tear breakup time (NIBUT), non-invasive average breakup time (NIAvg-BUT), ocular surface staining, Schirmer's test, and meibomiography. A crossover design with an additional 1-month follow-up was applied to both groups. Healthy subjects receiving the studied formulation exhibited good tolerability and no adverse events. Regarding the efficacy study, Group 1 exhibited a statistically significant reduction in the MMP-9 positivity rate compared to Group 2 (p < 0.001). Both Group 1 and Group 2 exhibited substantial improvements in OSDI and NIBUT scores (p < 0.001). However, Group 1 demonstrated a significant improvement in NI-Avg-BUT and Schirmer's test scores (p < 0.001), whereas Group 2 did not (p > 0.05). Finally, after the crossover, the proportion of MMP-9-positive subjects in Group 1 increased from 25% to 91.6%, while Group 2 showed a significant decrease from 87.5% to 20.8%. Overall, the topical formulation containing sesquiterpene helenalin from Arnica montana and hyaluronic acid was well tolerated and exhibited a favorable safety profile. Our formulation reduces DED symptomatology and modulates the ocular surface inflammatory process; this is evidenced by the enhancement of CIC, the improvement of DED-related tear film status, and the reduction of the MMP-9 positivity rate.

Effect of 3% Diquafosol Sodium on Dry Eye After Femtosecond Laser-Assisted In Situ Keratomileusis and Small Incision Lenticule Extraction Surgery in High-Myopic Eyes

PURPOSE

To evaluate the effect of 3% diquafosol sodium eye drop on dry eye after femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and small incision lenticule extraction (SMILE) in high-myopic eyes.

METHODS

Eighty-one cases with high myopia (162 eyes) who received FS-LASIK or SMILE were divided into four groups by surgical design and tear film stability: D-FS-LASIK (5s

RESULTS

The D-SMILE group showed increase in BUT postoperatively (1m: P =0.006, 3m: P =0.004), whereas C-FS-LASIK (1m: P =0.012) and C-SMILE (1m: P =0.036) groups showed decrease in BUT. Higher ΔBUT were observed in D-FS-LASIK (1m: P =0.027) and D-SMILE (1m: P =0.001, 3m: P =0.012) postoperatively. The D-FS-LASIK group showed less decrease than C-FS-LASIK group in Schirmer I. The D-SMILE group showed increase in Schirmer I, whereas C-SMILE showed decrease in 3 months. ΔOSDI was lower in D-SMILE group than in C-SMILE group (1m: P =0.026, 3m: P =0.035). Fatigue was severer in D-SMILE group than in C-SMILE group preoperatively ( P =0.019), although there was no significant difference postoperatively. Objective scattering index (1m: P =0.002, 3m: P =0.021) and tear film objective scattering index (1m: P =0.005, 3m: P =0.010) were lower in D-FS-LASIK group than in C-FS-LASIK group postoperatively. The D-FS-LASIK group showed better VA20% ( P =0.036) and VA9% ( P =0.027) than the C-FS-LASIK group 1 month postoperatively.

CONCLUSIONS

3% Diquafosol sodium eye drop was effective for SMILE and FS-LASIK-related dry eye in high-myopic eyes. It is necessary to focus on perioperative anti-dry eye management and especially pay attention to the eyes with risk factors, including unstable tear film, high myopia, and FS-LASIK surgery.

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Key Words Collapse

MESH Headings

• Humans
• Keratomileusis, Laser In Situ/adverse effects
• Hyaluronic Acid/therapeutic use
• Myopia/etiology
• Dry Eye Syndromes/drug therapy
• Dry Eye Syndromes/etiology
• Dry Eye Syndromes/surgery
• Lasers, Excimer/therapeutic use
• Ophthalmic Solutions
• Corneal Stroma/surgery

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Grants

• No. Z201100005520043 Beijing Municipal Science and Technology Commission

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Affiliation(s)

Dengxin Gao Beijing Ophthalmology and Visual Science Key Lab, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
Xiaotong Lv
Fengju Zhang
Yanzheng Song
Yushan Xu

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Dry eye disease and blinking behaviors: A narrative review of methodologies for measuring blink dynamics and inducing blink response

Dry eye disease (DED) is a leading cause of ophthalmology clinical encounters with prevalence ranging from 8.7% to 64% in various populations. Blinking is an endogenous process to refresh the tear film, clear debris and maintain quality vision. Altered blinking behavior is a common feature of DED and is implicated in the pathology of the disease. However, lack of a comprehensive review on the relationship between altered blinking behavior and DED is notable in the literature. Blinking behavior may be an effect of DED due to an unstable tear film sensitizing a motor response or be its cause due to destabilization of the tear film in conditions such as benign essential blepharospasm. In this comprehensive review, we summarize the current models and theories of tear film dynamics and blinking behavior to better understand their connection to DED and introduce contemporary technologies and measurement tools used in the evaluation and induction of blinking behavior. We also describe future directions of research to better understand the relationship between DED and blinking and explore therapies that address the abnormal blinking component of DED.

Objective Evaluation of Active Interactions between the Operator and Display Screen Equipment Using an Innovative Acquisition System

The occupational risk of operators using display screen equipment (DSE) is usually evaluated according to the extent of time spent in active operator-DSE interactions. Risk assessment is based on activity data collected through questionnaires. We evaluated an original and innovative system that can objectively assess active operator-DSE interactions by collecting electrical impulses generated by the activation of mouse, keyboard and a camera that collects attentive eye-screen fixation. The main aim of this study was to evaluate the system's performance on an employee sample involved in the task of active reading and copying at a DSE workstation connected to the system. In the context of mandatory health surveillance at work, we enrolled 38 DSE operators with normal neuropsychological and eye assessments who were required to complete two predefined reading and writing tasks. The obtained results show that the system is able to collect activity data derived from operator-DSE interactions through screen fixation, keyboard tapping and mouse handling. In the copying task, the session duration as recorded by the system was highly related to the screen fixation time. In the copying task, mouse and keyboard activities were more strongly related to session duration than screen fixation. For the copying task, it was also possible to obtain individual profiles of operator-DSE interactions while performing the same standardized tasks. Collected data can allow an objective evaluation of active time spent by DSE operators at their workstations, thus allowing a more accurate occupational health risk assessment and management. Prospective analysis of individual operator-DSE interaction profiles can favor the setup of targeted preventive and organizational interventions from an of even wider worker wellbeing perspective.

The work-related burden of dry eye

PURPOSE

To investigate the relationship between dry eye disease (DED) and work functioning, unemployment, absenteeism, and worry about job loss.

METHODS

DED and unemployment, absenteeism, and 'worry about job loss' were assessed in 71,067 subjects (18-65 years, 60% female) from the Dutch population-based Lifelines cohort using the Women's Health study questionnaire and single-item questions, respectively. Work functioning was assessed in 32,475 participants using the Work role functioning questionnaire 2.0. The relationships between DED and work measures were assessed with logistic regression models, corrected for age, sex, BMI, income, educational level, smoking, and 48 comorbidities.

RESULTS

8.3% of participants had DED and had more impaired work functioning compared to those without DED (49.2% vs 41.1%, OR 1.21, 95% CI 1.10-1.32, corrected for demographics, smoking and 48 comorbidities). DED carried a similar risk of impaired work functioning as rheumatoid arthritis. For participants with highly symptomatic dry eye impaired work functioning was even higher (59.1%) and similar to that of depression. The impaired work functioning seen with increasing symptoms were greater in undiagnosed subjects versus diagnosed subjects (P = 0.03). After correction for comorbidities, DED remained tied to absenteeism and increased worry about job loss, but not unemployment.

CONCLUSION

DED was linked to impaired work functioning and absence, but not unemployment. DEDs impact on work functioning is comparable to that of other severe chronic disorders, and undiagnosed subjects may be more affected. This highlights the importance of recognizing DED as a severe disorder and of screening for dry eye in the workplace to aid with diagnosis and treatment.

The relationship between sedentary behavior and dry eye disease

PURPOSE

Sedentary behavior (SB) has been linked with low-grade systemic inflammation, which could play a role in the development of dry eye disease (DED). This cross-sectional study aims to investigate the association between SB and DED.

METHODS

We assessed 48,418 participants from the population-based Lifelines cohort (58% female, 18-96 years). Women's Health Study (WHS)-defined DED was the primary outcome. SB was assessed using the Marshall Sitting Questionnaire. The relationship between DED and SB was analyzed using logistic regressions, corrected for age, sex, BMI, smoking status, demographics, and 48 comorbidities. Any potential modifying effect of physical activity (PA) was also assessed, and the analyses were repeated excluding the most computer-intensive domains, investigating SB independent from screen exposure.

RESULTS

WHS-defined DED was present in 9.1% of participants. Greater SB was associated with an increased risk of DED (odds ratio (OR) 1.015 per hour/day, 95%CI 1.005-1.024, P = 0.004). The association between SB and DED was only significant for those with less than WHO-recommended PA (OR 1.022, 95%CI 1.002-1.042, P = 0.027), and not in participants meeting WHO's recommendation (OR 1.011, 95%CI 0.999-1.023, P = 0.076). Lastly, when excluding computer-related sitting, the relationship between SB and DED was attenuated, and no longer significant (OR 1.009, 95%CI 0.996-1.023, P = 0.19).

CONCLUSIONS

Greater sedentary time was tied to an increased risk of DED, especially for those with lower PA levels than WHO recommendations. However, as there was no significant association when computer-intensive sitting time was excluded, screen use could explain the observed relationship and should be noted as a possible key confounder.

TFOS Lifestyle: Impact of the digital environment on the ocular surface

Eye strain when performing tasks reliant on a digital environment can cause discomfort, affecting productivity and quality of life. Digital eye strain (the preferred terminology) was defined as "the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing". Digital eye strain prevalence of up to 97% has been reported, due to no previously agreed definition/diagnostic criteria and limitations of current questionnaires which fail to differentiate such symptoms from those arising from non-digital tasks. Objective signs such as blink rate or critical flicker frequency changes are not 'diagnostic' of digital eye strain nor validated as sensitive. The mechanisms attributed to ocular surface disease exacerbation are mainly reduced blink rate and completeness, partial/uncorrected refractive error and/or underlying binocular vision anomalies, together with the cognitive demand of the task and differences in position, size, brightness and glare compared to an equivalent non-digital task. In general, interventions are not well established; patients experiencing digital eye strain should be provided with a full refractive correction for the appropriate working distances. Improving blinking, optimizing the work environment and encouraging regular breaks may help. Based on current, best evidence, blue-light blocking interventions do not appear to be an effective management strategy. More and larger clinical trials are needed to assess artificial tear effectiveness for relieving digital eye strain, particularly comparing different constituents; a systematic review within the report identified use of secretagogues and warm compress/humidity goggles/ambient humidifiers as promising strategies, along with nutritional supplementation (such as omega-3 fatty acid supplementation and berry extracts).

Spotlight on Digital Eye Strain

Digital Eye Strain (DES) is a clinical syndrome manifested with visual disturbances and/or ophthalmic dysfunction related to the usage of screen-enabled digital equipment. This term is gradually replacing the older term computer vision syndrome (CVS) that focused on the same symptoms found on personal computer users. DES is encountered more frequently during the past years due to the explosive increase in the usage of digital devices and subsequent increase in time in front of any screens. It presents with a series of atypical symptoms and signs stemming from asthenopia, dry eye syndrome, preexisting untreated vision issues and poor screen ergonomics. This review summarizes research data to date to determine whether the concept of DES has been conclusively defined and demarcated as a separate entity and if sufficient guidance is offered on professionals and the lay public. The maturity of the field, grouping of symptoms, examination techniques, treatment and prevention modalities are summarily presented.

A Practical Approach to Severity Classification and Treatment of Dry Eye Disease: A Proposal from the Mexican Dry Eye Disease Expert Panel

Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.

Influence of Prolonged Visual Display Terminal Use on Physical and Mental Conditions among Health Care Workers at Tertiary Hospitals, Taiwan

This study aimed to examine the effects of prolonged VDT working time on physical and mental health disadvantages among health care workers (HCWs) in tertiary hospitals based on their work characteristics, age, and sex. Included in the study were 945 and 1868 participants in the non-doctor/nurse and doctor/nurse groups, respectively. The questionnaire included VDT usage-related information, the Nordic Musculoskeletal Questionnaire (NMQ), computer vision syndrome (CVS), perceived occupational stress, burnout, the Brief Symptom Rating Scale-5 (BSRS-5), and self-rated health (SRH). After adjustment, multiple logistical regression analysis revealed that the two groups showed that the longer the VDT working time, the higher the risk of muscle pain, severe headaches, severe job stress, and self-assessed bad sleep quality. This showed that the condition of the doctor/nurse group was more severe than that of the non-doctor/nurse group. According to the stratified analysis by sex and age, in the group of women under the age of 30, the adjusted odds ratio value of physical and mental conditions increased with longer VDT working time and was statistically significant. The result show that it is important to reduce daily VDT exposure for doctor, nurses, and women under 30.