[Efficacy of sodium carboxymethylcellulose in the treatment of dry eye syndrome]

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.

Post-LASIK dry eye disease: A comprehensive review of management and current treatment options

Laser-assisted in situ keratomileusis (LASIK) is a unique corneal stromal laser ablation method that uses an excimer laser to reach beneath corneal dome-shaped tissues. In contrast, surface ablation methods, such as photorefractive keratectomy, include removing epithelium and cutting off the Bowman's layer and the stromal tissue of the anterior corneal surface. Dry eye disease (DED) is the most common complication after LASIK. DED is a typical multi-factor disorder of the tear function and ocular surface that occurs when the eyes fail to produce efficient or adequate volumes of tears to moisturize the eyes. DED influences quality of life and visual perception, as symptoms often interfere with daily activities such as reading, writing, or using video display monitors. Generally, DED brings about discomfort, symptoms of visual disturbance, focal or global tear film instability with possible harm to the ocular surface, the increased osmolarity of the tear film, and subacute inflammation of the ocular surface. Almost all patients develop a degree of dryness in the postoperative period. Detection of preoperative DED and committed examination and treatment in the preoperative period, and continuing treatments postoperatively lead to rapid healing, fewer complications, and improved visual outcomes. To improve patient comfort and surgical outcomes, early treatment is required. Therefore, in this study, we aim to comprehensively review studies on the management and current treatment options for post-LASIK DED.

Comparative antioxidant activity of various ophthalmic product types for artificial tears under different experimental conditions

Artificial tears or lubricants is a developing category in pharmaceutical research, due to the permanent increasing incidence of dry eye syndrome caused by the extensive use of personal computers and other gadget screens, associated with global warming and pollution. Considering the role of inflammation in dry eye syndrome, characterized by the production of free radicals, it is imperative to determine which elements are more significant in forming an artificial tear more effectively and more comfortably for the eye state and for the quality of life. Thus, the aim of the present study was to examine the evolution of the total antioxidant capacity of some frequently commercialized artificial tears via the photochemiluminescence method, using an antioxidant capacity of lipid soluble substances procedure, prior and subsequent to the exposure of these therapy agents to some physical agents. This is a preliminary research aiming to evaluate the impact of various environmental factors on these ophthalmic products, to be continued by evaluating whether the effectiveness of these products, in terms of objective examination and patient preference and adherence criteria, is impacted by the conditions of use and storage. Thus, the total antioxidant capacity of the evaluated artificial tear samples after UVC irradiation at 254 nm wavelength was studied, in order to investigate whether their status suffered any change in terms of antioxidant potential. In addition to the findings obtained in the study, some recommendations were also made.

Artificial Tears: Biological Role of Their Ingredients in the Management of Dry Eye Disease

Dry eye disease (DED) is the most common ocular surface disease, characterized by insufficient production and/or instability of the tear film. Tear substitutes are usually the first line of treatment for patients with DED. Despite the large variety of tear substitutes available on the market, few studies have been performed to compare their performance. There is a need to better understand the specific mechanical and pharmacological roles of each ingredient composing the different formulations. In this review, we describe the main categories of ingredients composing tear substitutes (e.g., viscosity-enhancing agents, electrolytes, osmo-protectants, antioxidants, lipids, surfactants and preservatives) as well as their effects on the ocular surface, and we provide insight into how certain components of tear substitutes may promote corneal wound healing, and/or counteract inflammation. Based on these considerations, we propose an approach to select the most appropriate tear substitute formulations according to the predominant etiological causes of DED.

Gel-Based Materials for Ophthalmic Drug Delivery

The most common route of administration of ophthalmic drugs is the topical route because it is convenient, non-invasive, and accessible to all patients. Unfortunately, drugs administered topically are not able to reach effective concentrations. Moreover, their bioavailability must be improved to decrease the frequency of administrations and their side effects, and to increase their therapeutic efficiency. For this purpose, in recent decades, particular attention has been given to the possibility of developing prolonged-release forms that are able to increase the precorneal residence time and decrease the loss of the drug due to tearing. Among these forms, gel-based materials have been studied as an ideal delivery system because they are an extremely versatile class with numerous prospective applications in ophthalmology. These materials are used in gel eye drops, in situ gelling formulations, intravitreal injections, and therapeutic contact lenses. This review is intended to describe gel-based materials and their main applications in ophthalmology.

Carboxymethyl Cellulose versus Hydroxypropyl Methylcellulose Tear Substitutes for Dry Eye Due to Computer Vision Syndrome: Comparison of Efficacy and Safety

Background:

Prolonged use of visual display terminal images on electronic devices such as computers frequently leads to symptoms of dry eye. Tear substitutes form the mainstay of treatment for mild-to-moderate dry eye.

Aim:

The study aimed to evaluate the efficacy and safety of carboxymethyl cellulose (CMC) versus hydroxypropyl methylcellulose (HPMC) tear substitutes for dry eye due to computer vision syndrome (CVS).

Materials and Methods:

This was a prospective, randomized, comparative, and open-labeled study. The efficacy of CMC 0.5% and HPMC 0.3% tear substitutes was compared in 180 participants (90 in each group) with dry eye. Change in Ocular Surface Disease Index (OSDI) score, Schirmer I test score, and tear film break up time (TF-BUT) were used as efficacy parameters. Safety was monitored on all visits.

Results:

The baseline OSDI score? 23.48 and 23.32 in Group A and B, respectively, decreased with treatment in both groups on all follow-up visits as compared to the baseline (day 90: 13.9 ± 3 vs. 14.81 ± 3.17, P: 0.01). The scores of Schirmer I test increased in both groups, with a greater improvement in Group A (at day 90: 22.75 ± 3.04 mm vs. 21.78 ± 3.36 mm, P: 0.04). The values of TF-BUT improved in both groups, the difference being statistically insignificant. An initial stinging was reported by one participant, each in both groups.

Conclusion:

CMC and HPMC tear substitutes were equally efficacious and safe in reducing symptoms of dry eye due to CVS.

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.

Comparative study of 0.1% hyaluronic acid versus 0.5% carboxymethylcellulose in patients with dry eye associated with moderate keratitis or keratoconjunctivitis

Background

Eye drops containing 0.1% hyaluronic acid (HA) and 0.5% carboxymethylcellulose (CMC) applied one drop three times a day per affected eye were compared in patients with moderate keratitis or keratoconjunctivitis related to dry eye disease (DED).

Patients and methods

This was a prospective, randomized, multicenter, Phase IIIB noninferiority study, with a single-masked phase in parallel mode with two groups over 84 days. The primary efficacy outcome was change in ocular surface (OS) staining between day 0 (D0) and day 35 (D35). The conjunctiva and cornea were stained with lissamine green and fluorescein. Secondary efficacy measures at day 84 (D84) were OS-staining score (SS), ocular comfort index, tear-film breakup time and how patients and investigators rated treatment efficacy and safety.

Results

At D35, 0.1% HA achieved a 46.6% reduction in OS-SS (−2.03±1.35 points, n=39 patients) and 0.5% CMC treatment, followed by a 34.9% reduction (−1.61±1.69 points, n=38 patients) compared to D0. At D84, the SS difference to D0 improved by −2.58±1.45 points (−59.2%) for 0.1% HA and −2.59±2.27 points (−54.4%) for 0.5% CMC. Ocular comfort-index scores improved, with significantly lower (better) values for stinging and itching on D84 for 0.1% HA. Patients assessed treatment with 0.1% HA as significantly better than 0.5% CMC (Likert scale, 4.82 vs 3.97; P=0.018). Four adverse events (AEs) occurred in four of 41 patients (9.8%) treated with 0.1% HA, and three AEs in two of 39 patients (5.1%) treated with 0.5% CMC. No serious AEs were noted.

Conclusion

DED signs and symptoms of DED significantly improved with both eye drops. OS staining improved >54% at D84. Treatment was well tolerated, with only minor AEs <10%. 0.1% HA and 0.5% CMC were equally safe and effective. Significant and nonsignificant results were constantly in favor of 0.1% HA.

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.