Management of inflammation in dry eye disease: Recommendations from a European panel of experts

Patients' knowledge, attitudes, and practices regarding lifestyle related dry eye

Rising incidences of dry eye, often attributed to modern lifestyle and environmental factors, highlight the need for knowledge, attitudes, and practices (KAP) studies to inform tailored interventions. This study evaluated patients' KAP concerning lifestyle-related dry eye at the Ophthalmology Hospital of the China Academy of Chinese Medical Sciences from July 1 to July 26, 2024. A self-designed questionnaire was used to gather demographic data and assess KAP scores, yielding 556 valid responses (98.93%). Among participants, 342 (61.51%) were female, with a mean age of 39.26 ± 13.56 years. Mean KAP scores were 7.44 ± 4.65 (knowledge), 35.20 ± 4.10 (attitude), and 35.77 ± 6.15 (practice). Mediation analysis indicated direct influences of age and familial dry eye history on knowledge, with knowledge impacting attitude, and various factors influencing practice. While patients exhibited limited knowledge, they generally held positive attitudes and engaged in proactive practices. Enhancing patient education on lifestyle factors related to dry eye is essential to boost knowledge and foster effective prevention and management strategies.

Excessive screen time exposure leads to dry eyes and inflammatory conjunctivitis in children

BACKGROUND

The rise in usage of smartphones and digital devices among pediatric population has raised concerns about their eye's health. It is of particular interest in relation to dry eye disease (DED) and inflammatory conjunctivitis. Prolonged screen exposure is linked to reduced blink rates, tear evaporation, and tear break-up time (TBUT), that can lead to ocular discomfort and tear instability.

OBJECTIVE

To find association between excessive screen time, dry eye disease, and inflammatory conjunctivitis in children aged 3 to 11 years.

METHODS

A cross-sectional correlational study was conducted at a tertiary care hospital Islamabad. Non-probability purposive sampling technique was adopted. Detailed ophthalmic examinations, including TBUT and blink rate assessments, were performed. The relationship between excessive screen time, TBUT, blink rate, and inflammatory conjunctivitis was assessed using multivariate analysis. A 95% confidence interval was kept significant.

RESULTS

A total of 479 participants aged 6.7 ± 1.9 were included. The mean screen time was 4.52 ± 1.49 hour/day, while mean TBUT was 10.29 ± 3.17. A significant negative relationship was found between screen time and TBUT (B =  - 0.351, p < 0.001). The TBUT and inflammatory conjunctivitis showed a significant relationship (χ2 = 134.1(3); p value < 0.001). A significant relationship was also found among dry eyes and children having a dedicated gadget (χ2 = 27.6(3); p value < 0.001). Blink rate was directly associated with TBUT (p < 0.001). Approximately 48.64% of participants exhibited abnormal Tear Break-Up Time (TBUT).

CONCLUSION

Excessive screen time is significantly associated with reduced TBUT and a lower blink rate in children, contributing to dry eye disease and inflammatory conjunctivitis.

Role of Chinese Medicine Monomers in Dry Eye Disease: Breaking the Vicious Cycle of Inflammation

Dry eye disease (DED) is a chronically inflammatory ocular surface disorder of unknown pathogenesis. Anti-inflammatory medications, artificial tears, autologous serum, and LipiFlow have been shown to be highly beneficial in alleviating symptoms. Nevertheless, these interventions often provide only short-term results and do not address the underlying problems of the disease. There is growing evidence that the risk of DED is associated with a vicious cycle of inflammation. This vicious cycle of inflammation is produced by the interaction of several factors, including tear film hyperosmolarity, tear film instability, inflammation, and apoptosis. Chinese medicine monomers, distinguished by their multicomponent and multitarget advantages, have been shown to help treat DED by modulating tear film status, and inhibiting inflammatory responses, and apoptosis, providing a new way of thinking of the management of DED in Chinese medicine.

Exploring New and Global Therapeutic Options for Dry Eye Disease: What You Need to Know

ABSTRACT

Dry eye disease (DED) is a complex condition characterized by the loss of tear film homeostasis, resulting in ocular symptoms, inflammation, and damage. Managing DED involves a diverse range of therapies aimed at alleviating symptoms and addressing underlying causes. This review provides a comprehensive update on current DED treatments, focusing on medications approved by the United States (US) Food and Drug Administration and notable treatments available outside the United States. Differences in treatment approaches between Asian and Western countries have been explored, highlighting the need for a nuanced understanding of regional variations. The Asia Dry Eye Society offers a new perspective on dry eye, further elucidating these regional distinctions. This review emphasizes the importance of staying informed about evolving treatment guidelines and advancements in DED therapeutics. As the field progresses with new and innovative therapies, there is increased potential for improved patient management and enhanced quality of life for individuals affected by DED.

New Eye Drop Formulation Based on Desonide and Xanthan Gum in Dry Eye Disease: Nonclinical Studies

Background/Objectives: A novel ophthalmic formulation, XanterDES, containing 0.2% xanthan gum and 0.025% desonide sodium phosphate (DES), was developed to alleviate ocular surface discomfort and irritation. This study aimed to evaluate its pharmacodynamic properties and to characterize its rheological behavior and mucoadhesive characteristics, compared to another formulation containing 0.2% hyaluronic acid and 0.001% hydrocortisone (HYD). Methods: A rabbit (New Zealand White) model of LPS-induced uveitis was used to test different concentrations of DES on ocular markers of inflammation. The efficacy of XanterDES and HYD on induced dry eye was evaluated by assessing tear volume and corneal damage in C57BL/6 mice exposed to a controlled environmental chamber. The rheological and mucoadhesive properties of XanterDES and HYD were assessed using a HAAKE RheoStress RS600 rheometer and a TA-XT2 texture analyzer, respectively. Results: In the uveitis model, unlike DES 0.25%, a low concentration of 0.025% DES showed a significant inhibitory activity localized to the eye surface and effectively reduced corneal edema. In the dry eye model, XanterDES demonstrated superior efficacy compared to HYD, effectively preventing both tear volume reduction and corneal damage. XanterDES also demonstrated pseudoplastic and enhanced mucoadhesive properties compared to HYD. Conclusions: The ancillary anti-inflammatory effects of a low dose of DES combined with the biophysical properties of xanthan gum are supportive of a favorable therapeutic profile, promoting the maintenance or restoration of ocular surface homeostasis while minimizing the risk of adverse effects typically associated with standard-dose corticosteroids. The comparison with another low-dose corticosteroid highlights the superiority of XanterDES in pharmacodynamic and biophysical performance.

Effect of 0.05% cyclosporine A eye drops on the healing process of corneal epithelial defects in rats

0.05% cyclosporine A eye drops is a kind of new medication for dry eye after corneal refractive surgeries. However, it is still unclear how this eye drops affect the healing process of corneal epithelial defects caused by operative procedures. In this vivo study, the effect of 0.05% cyclosporine A eye drops on the healing process of the corneal epithelium was assessed in a rat model featuring mechanically induced central corneal epithelial defects. These Sprague-Dawley rats were randomly divided into three groups, the 0.05% cyclosporine A eye drops group (CsA group), the 0.1% sodium hyaluronate eye drops group (HA group), and the model control group (MC group). The epithelial healing, tear secretion, epithelial microvilli, expression of apoptosis markers (TUNEL, p53, and bcl-2 proteins), inflammatory factors (IL-1β, TNF-α, and IL-6), and epidermal growth factor (EGF) were detected in the current study using corneal fluorescein sodium staining, phenol red thread test, transmission electron microscopy (TEM), immunofluorescence, and enzyme-linked immunosorbent assay (ELISA), respectively. Compared to the other two groups, lower expression of apoptosis markers and inflammatory factors were exhibited in the CsA group, along with its faster and better epithelial healing and higher tear secretion (P < 0.05). In conclusion, 0.05% cyclosporine A eye drops effectively promote the healing process for corneal epithelial defects in rats, potentially offering advantages for rapid corneal recovery after refractive surgical procedures.

Pooled results from two pivotal randomized controlled clinical trials: ESSENCE-1 and ESSENCE-2 to assess efficacy and safety of a water-free ciclosporin 0.1% formulation for the treatment of dry eye disease

PURPOSE

This pooled analysis of two pivotal studies (ESSENCE-1 and ESSENCE-2) evaluated treatment effects of a water-free ciclosporin 0.1% solution in dry eye disease (DED) patients in the overall population and in subgroups according to sex, age, and baseline severity of disease.

METHODS

In these randomized, multicenter, double-masked, vehicle-controlled studies patients received ciclosporin 0.1% or vehicle (1:1 ratio) in both eyes twice daily for 85 and 29 days, respectively. Total and central corneal fluorescein staining (tCFS; cCFS; NEI scale, 0-15) were assessed at Day 15 and 29. Other endpoints included conjunctival staining and blurred vision scores. Safety and tolerability parameters comprised adverse events, ophthalmic examinations and drop comfort assessments.

RESULTS

In total 1162 patients were included in the analysis (585 ciclosporin 0.1%; 577 vehicle). Patients age (mean [SD]: 58.3 [15.23] years) and gender distribution (73% females) are consistent with DED epidemiology. Change from baseline (LS mean [SE]) in tCFS significantly improved compared to vehicle, both at Day 15 (ciclosporin: -3.24 [0.112]; vehicle -2.71 [0.113]; Δ= -0.52 [0.144], p=0.0003) and Day 29 (ciclosporin: ‑3.83 [0.115]; vehicle:‑3.30 [0.116]; Δ: ‑0.53 [0.147], p=0.0003). 56.8% and 66.4% of patients responded to ciclosporin 0.1% with a tCFS improvement of ≥ 3 scores on Day 15 and 29, respectively. A consistent effect on tCFS favoring ciclosporin over vehicle was observed in all subgroups. Improvements favoring ciclosporin were seen in cCFS and conjunctival staining in the overall population and in blurred vision score in patients with significant corneal staining. Incidence of ocular adverse events was 13.2% in both treatment groups. Mild instillation site reactions were reported by 7.9% patients in the ciclosporin group. Discontinuation rates were low with 2.6% and 2.1% in ciclosporin and vehicle groups. Ciclosporin 0.1% was rated comfortable upon instillation by 84.7% of patients.

CONCLUSION

The pooled analysis confirmed that the water-free ciclosporin 0.1% solution is effective in improving ocular surface staining after 2 weeks of treatment to a clinically relevant extent in more than 50% of patients in the overall population and subgroups. With an early onset and good tolerability, the product has the potential to address an unmet medical need in DED.

CLINICALTRIALS

GOV IDENTIFIER

 NCT03292809 on 21-July-2017; NCT04523129 on 20-August-2020 KEY MESSAGES: What Was Known: Ciclosporin eye drops are a standard of care in dry eye disease (DED) therapy not controlled by artificial tears. A novel water-free ciclosporin 0.1% ophthalmic solution with improved efficacy has recently been commercialized in the United States and approved in the European Union.

WHAT THIS PAPER ADDS

The water-free cyclosporine 0.1% solution showed consistent and early improvement of ocular surface damage in patients with moderate and severe dry eye disease as well as in subgroups according to age and sex. Responder analysis showed the clinical relevance of these improvements in more than 50 % of treated patients after 2 weeks of treatments. This eye drop formulation was well tolerated and no new safety signals were detected.

Topical Application of 0.05% Cyclosporine for the Treatment of Neurotrophic Keratopathy Secondary to Herpes Simplex Keratitis

PURPOSE

The purpose of this study was to assess the effectiveness and tolerability of 0.05% cyclosporine A (CsA) eye drops for neurotrophic keratopathy (NK) secondary to herpes simplex keratitis (HSK).

METHODS

Fifteen patients (15 eyes) with prior HSK and secondary NK, classified as stage 2 or 3 on the basis of the Mackie classification, were enrolled. All patients received a combined treatment regimen of 0.05% CsA eye drops (1 drop 4 times daily), a silicone hydrogel bandage contact lens, and 0.15% ganciclovir ophthalmic gel (1 drop 3 times daily). For patients achieving corneal healing, CsA was continued at a reduced dosage of twice daily for an additional 2 months and other treatments were discontinued. Follow-ups were scheduled at weeks 1, 2, 3, and 4 and at months 2 and 3 after treatment initiation, followed by a 3-month follow-up period. Key outcomes, including best-corrected visual acuity, Schirmer I test, and corneal sensitivity, were assessed at each visit before and after treatment.

FINDINGS

Significant reductions were observed in the area of corneal defects, expressed as proportion of total corneal area, throughout follow-up period. Complete corneal healing was achieved by 13.3% of patients by week 2, 60.0% by week 3, 86.7% by week 4, and 100.0% by week 8, with the mean (SD) time to healing being 3.8 (1.8) weeks (range, 2-8 weeks). Additionally, significant improvements were noted in diseased eyes for best-corrected visual acuity, tear secretion (Schirmer I test values), and corneal sensitivity after treatment.

IMPLICATIONS

CsA eye drops, with bandage lenses and ganciclovir, effectively resolve NK from HSK, without adverse effects. This combination therapy shows promise for future clinical use and research.

CLINICAL TRIAL REGISTRATION

Our study is a retrospective observational study because it involves the analysis of previously collected data, so the study was not registered prior to its commencement. However, if it is necessary for publication, we are willing to proceed with retrospective registration.

Real-world insights and outcomes related to ciclosporin A 0.1% cationic emulsion for the long-term treatment of dry eye disease in Germany: Country-level sub-analysis of the PERSPECTIVE study

PURPOSE

The PERSPECTIVE study was a real-world European, non-interventional, multicenter, observational study that evaluated the effectiveness, tolerability, and safety of ciclosporin A (CsA) 0.1% cationic emulsion (CE) in routine clinical practice as a treatment for adults with severe keratitis and dry eye disease (DED) that remained insufficiently controlled with artificial tears. This sub-analysis examined data from ophthalmology clinics in Germany to provide more precise insights into treatment patterns, outcomes, and clinical decision-making related to CsA 0.1% CE.

METHODS

Study data were collected from adults starting CsA 0.1% CE (one drop in both eyes at bedtime) and followed up at Week 4, 12, and 24, and Month 12. The primary endpoint was mean change from baseline in corneal fluorescein staining (CFS) score (Oxford Grade Scale) at Month 12. Secondary endpoints examined the severity of ocular signs and symptoms, and adverse events (AEs).

RESULTS

A total of 236 patients from 20 ophthalmology clinics in Germany participated in the PERSPECTIVE study (69.9% female; mean age 60.8 years). Following treatment with CsA 0.1% CE, patients experienced significant reductions in CFS score from Week 4, which were maintained through to Month 12 (P < 0.0001). From baseline, 81.6% of patients experienced an improvement in CFS score at Month 12. CsA 0.1% CE provided significant reductions in the severity of eyelid and conjunctival erythema at Month 12 compared with baseline (P < 0.001), as well as significant reductions in the severity of subjective ocular symptoms (all P ≤ 0.015). Safety data were consistent with the known safety profile of CsA 0.1% CE. Tolerability was rated as "satisfactory," "good," or "very good" by 97.2% of physicians and 95.7% of patients.

CONCLUSION

Outcomes in Germany were similar to those reported for the overall European study population and are indicative of the treatment results that ophthalmologists may expect to see with CsA 0.1% CE treatment in real-life clinical practice. Treatment with CsA 0.1% CE provided long-term improvements over 12 months and was generally well tolerated.

Tolerability of Current Treatments for Dry Eye Disease: A Review of Approved and Investigational Therapies

Dry eye disease (DED) is a common, multifactorial ocular disease impacting 5% to 20% of people in Western countries and 45% to 70% in Asian countries. Despite the prevalence of DED and the number of treatment approaches available, signs and symptoms of the disease continue to limit the quality of life for many patients. Standard over-the-counter treatment approaches and behavior/environmental modifications may help some cases but more persistent forms often require pharmacological interventions. Approved and investigational pharmaceutical approaches attempt to treat the signs and symptoms of DED in different ways and tend to have varying tolerability among patients. While several pharmacological approaches are the standard for persistent and severe disease, mechanical options provide alternate treatment modalities that attempt to balance efficacy and comfort. Newer approaches target the causes of DED, utilizing novel delivery methods to minimize irritation and adverse events. Here, we review approved and investigational approaches to treating DED and compare patient tolerability.

Quercetin inhibits hypertonicity-induced inflammatory injury in human corneal epithelial cells via the PTEN/PI3K/AKT pathway

Dry eye is a prevalent ophthalmic disease. Ocular surface inflammation in the hyperosmolar environment of the tear film is critical in dry eye progression. Quercetin has strong anti-inflammatory effects; however, its exact mechanism of action in dry eye is not fully understood. Therefore, this study investigated whether quercetin could inhibit the damage sustained to human corneal epithelial cells (HCECs) in a hyperosmolar environment through its anti-inflammatory effects. HCECs were cultured in a complete medium and were divided into four groups: normal, model, quercetin, and inhibitor. The proliferation of HCECs was detected by Ki67 staining; the expression levels of PTEN, p-PI3K and p-AKT were detected by Western blotting and immunofluorescence staining; the relative mRNA expression levels of PTEN, PI3K, AKT, IL-6 and TNF-ɑ were detected by quantitative real-time PCR; the relative expression levels of IL-6 and TNF-α were detected by enzyme-linked immunosorbent assay. In this study, the proliferation of HCECs in the model group was found to be significantly inhibited compared with that in the normal group; however, quercetin was effective in improving the proliferation of HCECs, decreasing the relative expression of p-PI3K, p-AKT, IL-6, TNF-ɑ as well as increasing PTEN. In conclusion, this study demonstrated that quercetin could promote the proliferation of HCECs and reduce the expression of inflammatory factors by inhibiting the PTEN/PI3K/AKT pathway in the hyperosmolarity-induced HCECs model.

Novel treatments for dry eye syndrome

Dry eye syndrome (DES) is a prevalent and multifactorial disease that leads to a self-perpetuating cycle of inflammation and damage to the ocular surface. This results in symptoms such as redness, burning, and blurred vision, which can negatively affect a patient's quality of life. While treatments are available to manage DES, they only temporarily relieve symptoms. Furthermore, long-term use of certain medications can cause harm to the ocular surface. Therefore, there is a need for safer and effective treatments for DES. This review highlights the latest advancements in DES therapy, providing valuable insights into ongoing efforts to improve patient outcomes.

New Korean Guidelines for the Diagnosis and Management of Dry Eye Disease

New Korean guidelines for the diagnosis and management of dry eye disease were developed based on literature reviews by the Korean Dry Eye Guideline Establishment Committee, a previous dry eye guideline by Korean Corneal Disease Study Group, a survey of Korean Dry Eye Society (KDES) members, and KDES consensus meetings. The new definition of dry eye was also proposed by KDES regular members. The new definition by the regular members of the KDES is as follows: "Dry eye is a disease of the ocular surface characterized by tear film abnormalities and ocular symptoms." The combination of ocular symptoms and an unstable tear film (tear breakup time <7 seconds) was considered as essential components for the diagnosis of dry eye. Schirmer test and ocular surface staining were considered adjunctive diagnostic criteria. The treatment guidelines consisted of a simplified stepwise approach according to aqueous deficiency dominant, evaporation dominant, and altered tear distribution subtypes. New Korean guidelines can be used as a simple, valid, and accessible tool for the diagnosis and management of dry eye disease in clinical practice.

[The place of ciclosporin A cationic emulsion 0.1% in the therapy of xerophthalmia]

Dry eye disease (DED) is pathogenetically based on inflammation of the ocular surface. A step-by-step approach to DED treatment involves early initiation of anti-inflammatory therapy, including instillation of cyclosporine A (CsA). However, recommendations for the use of topical CsA in clinical practice are limited. This article presents an expert consensus on practical recommendations for the management of patients with DED, including indications, time of initiation and duration of CsA therapy, comparison of CsA forms currently registered in the Russian Federation, as well as issues of patient education.

Exploring the Cutting Edge of Vision Science: New Developments in Diagnostics and Treatment of Ocular Surface in Dry Eye Disease

The ocular surface refers to the outermost layer of the eye, which includes the cornea, conjunctiva and eyelids [...].

Dealing with the Persistent Pathogenic Issues of Dry Eye Disease: The Importance of External and Internal Stimuli and Tissue Responses

The immune system plays a central role in protecting the ocular surface from exogenous and endogenous insults, maintaining tissue homeostasis thanks to the mechanism of para-inflammation. This physiological adaptive response may induce resident macrophages/monocytes to produce cytokines and growth factors in order to promote epithelial cell recovery. In case of well-controlled para-inflammation, caused by a low amount of stress, cell viability and function are maintained. When stress becomes too intense, there is a response characterized by the activation of autophagic pathways and consequent cell death. Dysregulated homeostasis and chronic sub-clinical inflammation are the starting points for the development of a stable, chronic inflammatory disease, which leads to ocular surface damage, and, in turn, to the onset or progression of chronic dry eye disease (DED). The long-term management of DED should consider all of the pathogenic issues involved in the disease, including the control of persistent external or internal stresses that are capable of activating and maintaining the para-inflammatory adaptive mechanisms, potentially leading to full-blown inflammation. Dysregulated para-inflammation can be corrected by means of the prolonged use of tear substitutes containing minimal doses of safe corticosteroids or other anti-inflammatory molecules (e.g., corticosteroid, cyclosporine) in order to re-equilibrate ocular surface homeostasis.