The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects

A major review of punctal stenosis: Updated anatomy, epidemiology, etiology, and clinical presentation

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Lacrimal gland activity in lacrimal drainage obstruction: exploring the potential cross-talk between the tear secretion and outflow

PURPOSE

To investigate the effects of lacrimal drainage obstructions on the lacrimal gland activity and if there exists a potential link between the two.

METHODS

Direct assessment of the lacrimal gland activity from the palpebral lobe was performed in consecutive patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO), along with Ocular Surface Disease Index (OSDI), non-invasive tear break up time (NIBUT; Oculus K5M), tear meniscus height and Schirmer I. The primary outcome measure was the difference in the tear flow rate between the eye with PANDO and the contralateral uninvolved eye.

RESULTS

Thirty patients (median age, 45.5 years; 25 females) with unilateral PANDO had epiphora for a mean duration of 20 months. The mean OSDI score was 6.3. NIBUT (mean 11.56 vs 11.58 s; p=0.49) and Schirmer I values (mean 18.83 vs 19.4 mm; p=0.313) were not significantly different between PANDO and non-PANDO eyes. The morphology of the palpebral lobe (size 29.3 vs 28.6 mm2, p=0.41) and the number of lacrimal ductular openings (median 2 vs 2.5) were similar between the two eyes. The mean tear flow from the lacrimal glands of the PANDO side was significantly reduced compared with the contralateral uninvolved side (0.8 vs 0.99 µL/min; p=0.014)).

CONCLUSION

Tear flow rate from palpebral lobes of patients with unilateral lacrimal outflow obstruction shows a significant reduction compared with the contralateral side. The potential ways of communications between the tear drainage and the tear production mechanisms need to be explored further.

Advances in the ocular complications after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has benefited an increasing number of patients with hematological disease in the clinic. It is a curative therapy for malignant and nonmalignant hematological diseases. With the advancement and further clinical application of HSCT in recent years, the life expectancy of patients has increased, but complications have become more common. The occurrence of ocular complications is receiving increasing attention because they can seriously affect the quality of life of patients. Ocular complications require increased attention from clinicians because of their negative impact on patients and increasing incidence. Most of recent reports on posttransplant ocular complications involve ocular manifestations of graft-versus-host disease (GVHD), and a few ocular complications that do not originate from GVHD have also been reported. This review summarizes the diagnosis, scoring criteria, pathophysiology, and clinical manifestations of and common therapies for ocular graft-versus-host disease(oGVHD) after HSCT, and includes a description of some rare cases and novel therapies.

Botulinum Neurotoxin Type a Injection Combined with Absorbable Punctal Plug Insertion: An Effective Therapy for Blepharospasm Patients with Dry Eye

Blepharospasm patients often have dry eye manifestations. Botulinum neurotoxin type A (BoNT-A) injection has been the main management for blepharospasm and absorbable punctal plug (APP) insertion is shown to be effective in the treatment of dry eye. However, there have been no studies investigating the combined treatment of BoNT-A and APP in blepharospasm patients with dry eye. In this retrospective study, 17 blepharospasm patients with dry eye treated by BoNT-A injection and 12 receiving BoNT-A plus APP treatment were enrolled. The efficacy was evaluated according to the Jankovic rating scale, Ocular Surface Disease Index (OSDI), fluorescein staining (FL), fluorescein tear break-up time (FBUT) and Schirmer I test (SIT). Both BoNT-A and BoNT-A+APP treatment effectively reduced the functional impairment of blepharospasm. At baseline, all the patients had high OSDI scores (BoNT-A group: 82.48 ± 7.37, BoNT-A+APP group: 78.82 ± 4.60, p = 0.112), but relatively low degrees of FL (BoNT-A group: 3.18 ± 1.01, BoNT-A+APP group: 3.50 ± 1.24, p = 0.466), FBUT (BoNT-A group: 1.71 ± 0.77, BoNT-A+APP group: 2.17 ± 0.58, p = 0.077) and SIT (BoNT-A group: 2.53 ± 0.99, BoNT-A+APP group: 3.17 ± 1.23, p = 0.153). After treatment, OSDI, FL, FBUT and SIT were all obviously restored in the two groups. When comparing the changing rates, only OSDI (BoNT-A group: -52.23% ± 15.57%, BoNT-A+APP group: -61.84% ± 9.10%, p = 0.047) and FL (BoNT-A group: -22.55% ± 25.98%, BoNT-A+APP group: -41.94% ± 14.46%, p = 0.016) showed significant differences between the two groups. This study suggests that OSDI is not applicable in the diagnosis of dry eye among blepharospasm patients. For blepharospasm patients with severe dry eye symptoms, especially those with fluorescein staining in the cornea, the combined treatment of BoNT-A and APP is more effective than using BoNT-A alone.

Quantitative analysis of both lacrimal glands in unilateral primary acquired nasolacrimal duct obstruction, based on three-dimensional fast spin echo-Cube-Flex

OBJECTIVE

To investigate whether unilateral primary acquired nasolacrimal duct obstruction (PANDO) changes the volume and water fraction of both lacrimal glands, using three-dimensional fast spin echo (3D-FSE)-Cube-Flex images, and to identify whether the lacrimal gland is a target organ in this disease.

METHODS

3D-FSE-Cube-Flex images of both lacrimal glands in 25 healthy volunteers and 31 patients with unilateral PANDO were retrospectively reviewed. The differences in volume and water content in the lacrimal glands between the controls, non-PANDO side, and PANDO side groups were examined. Moreover, the associations between magnetic resonance imaging (MRI) parameters and disease duration were assessed with correlation analysis.

RESULTS

The lacrimal gland volumes were not significantly different between the PANDO and non-PANDO side groups, compared to the control group (P = 0.484). However, the gland volumes tended to be increased bilaterally in patients with PANDO. In contrast, the gland water fractions in the PANDO and non-PANDO side groups were significantly higher than those in the control group (P = 0.009 and P = 0.014, respectively), and similar between the non-PANDO and PANDO side groups (P = 0.897). No correlation was found between the disease duration and the gland MRI parameters (volume and water fraction).

CONCLUSIONS

Both lacrimal glands are affected by unilateral PANDO. A change in the water fraction of these glands appears to precede the change in volume and may be a sensitive early indicator.

Tear instability in the fellow eye of unilateral nasolacrimal obstruction and resolution with dacryocystorhinostomy

PURPOSE

To determine the effect of unilateral primary acquired nasolacrimal obstruction (PANDO) on ocular surface parameters in PANDOeyes and fellow eyes and changes in these parameters after dacryocystorhinostomy.

METHODS

Tear osmolarity, tear break-up time (TBUT), Schirmer's test, Meibomian gland score, and Lissamine Green staining of PANDO eyes and fellow eyes were measured preoperatively and postoperatively at Day 15, 1 month, and 3 months. Lacrimal irrigation and epiphora symptomatology were evaluated at all follow-up visits, and patients who did not meet surgical success criteria were excluded from the study.

RESULTS

Twenty-nine patients who underwent successful dacryocystorhinostomy surgery were included in the study. Preoperative and postoperative Day 15 Schirmer (p = .019, p = .001) and TBUT (p = .039, p = .043) were significantly lower in the fellow eye compared to PANDO eyes. The differences observed between PANDO eyes and fellow eyes in all other parameters were not significant (p > .05). Preoperatively PANDO eye parameters were normal, whereas TBUT (7.59 ± 5.39 s) and tear osmolarity (308.59 ± 17.32 mOsm/L) values of the fellow eye may be indicative of tear film instability. TBUT and tear osmolarity of the fellow eye showed significant improvement 3 months postoperatively compared to preoperative values (p = .010; p = .027 respectively).

CONCLUSION

Schirmer and TBUT values of the fellow eye were significantly lower than PANDO eyes preoperatively, one month after surgery there was no significant difference. TBUT and tear osmolarity of the fellow eyes may be indicative of tear instability preoperatively with improvement 3 months after dacryocystorhinostomy.

Reduced tear break-up time in the fellow eye of patients with unilateral primary acquired nasolacrimal duct obstruction

PURPOSE

To measure tear osmolarity, Schirmer I test and tear break-up time (TBUT) values in the obstructed and non-obstructed fellow eye of unilateral primary acquired nasolacrimal duct obstruction (PANDO) patients and compare them with healthy controls.

METHODS

In this prospective noninterventional study, the tear osmolarity, Schirmer I test, and TBUT values from unilateral PANDO eyes, fellow eyes, and control eyes of all subjects were measured.

RESULTS

The study included 114 eyes of 30 PANDO patients as well as 27 healthy controls. There was a significant difference between TBUT and Schirmer values of fellow eyes and PANDO eyes (p = 0,035; p = 0,001). There was no significant difference in any of the ocular surface parameters between PANDO eyes and control eyes (p > 0.05). When fellow eyes were compared to control eyes, there was a significant difference in TBUT (p = 0.046).

CONCLUSIONS

Decreased TBUT was exhibited by the fellow eye of unilateral PANDO patients, compared to the PANDO side and controls. Compensatory changes in PANDO eyes due to a decrease in the tear secretion reflex may lead to tear dysfunction of the fellow eye. Clinicians should assess tear stability in the fellow eye of PANDO patients as this could be leading to added symptomatic complaints.

Efficacy and retention of silicone punctal plugs for treatment of dry eye in patients with and without ocular graft-versus-host-disease

PURPOSE

To examine the retention rates and efficacy of silicone punctal plugs for the treatment of dry eye disease (DED) in patients with ocular graft-versus-host-disease (oGVHD) in comparison to dry eye disease due to non-oGVHD etiologies.

METHODS

We reviewed the case-records of 864 consecutive patients with DED who were symptomatic despite topical therapy and had silicone punctal plugs placed over an eight-year- period at a single academic center. We compared plug retention rates in oGVHD and non-oGVHD DED patients using Kaplan-Meier analyses. Furthermore, we analyzed changes in objective ocular surface parameters including tear breakup time (TBUT), Schirmer's test, and corneal fluorescein staining (CFS) score in plug-retaining patients at two-, six- and twelve-month follow-up.

RESULTS

Median age of dry eye patients was 58 years, and 606 (70%) of patients were women. In the cohort, 264 (31%) patients were diagnosed with oGVHD. Plug retention was significantly lower in oGVHD-DED patients compared to non-oGVHD-DED patients (p < 0.0001). We observed significant improvement in CFS scores in plug retaining-oGVHD and non-oGVHD DED patients at all time points. Tear break-up time was significantly prolonged at six- and twelve-months follow-up in non-oGVHD patients, whereas significant change in TBUT in oGVHD patients was recorded only at twelve months post plug placement. Schirmer's score improved significantly in plug retaining-non-oGVHD DED patients at six- and twelve-months follow-up, however no significant change was observed in Schirmer's score in oGVHD DED patients.

CONCLUSIONS

An improvement in ocular surface disease parameters was observed in both plug-retaining oGVHD and non-oGVHD DED patients. However, a majority of oGVHD DED patients spontaneously lost their punctal plugs within 90 days of placement. Therefore, regular follow-up after plug placement is recommended to detect plug loss and ensure adequate disease control.

Comparison of cytotoxicities and anti-allergic effects of topical ocular dual-action anti-allergic agents

Background

To investigate the cytotoxicities of the topical ocular dual-action anti-allergic agents (alcaftadine 0.25%, bepotastine besilate 1.5%, and olopatadine HCL 0.1%) on human corneal epithelial cells (HCECs) and their anti-allergic effects on cultured conjunctival epithelial cells.

Methods

A Methylthiazolyltetrazolium(MTT)-based calorimetric assay was used to assess cytotoxicities using HCECs at concentrations of 10, 20 or 30% for exposure durations of 30 min, 1 h, 2 h, 12 h or 24 h. Cellular morphologies were evaluated by inverted phase-contrast and electron microscopy. Wound widths were measured 2 h, 18 h, or 24 h after confluent HCECs monolayers were scratched. Realtime PCR was used to quantify anti-allergic effects on cultured human conjunctival cells, in which allergic reactions were induced by treating them with Aspergillus antigen.

Results

Cell viabilities decreased in time- and concentration-dependent manners. Cells were detached from dishes and showed microvilli loss, cytoplasmic vacuoles, and nuclear condensation when exposed to antiallergic agents; alcaftadine was found to be least cytotoxic. Alcaftadine treated HCECs monolayers showed the best wound healing followed by bepotastine and olopatadine (p < 0.0001). All agents significantly reduced the gene expressions of allergic cytokines (IL-5, IL-25, eotaxin, thymus and activation-regulated chemokine, and thymic stromal lymphopoietin) and alcaftadine had the greatest effect (p < 0.0001 in all cases).

Conclusions

Alcaftadine seems to have less side effects and better therapeutic effects than the other two anti-allergic agents tested. It may be more beneficial to use less toxic agents for patients with ocular surface risk factors or presumed symptoms of toxicity.

Outcome of External Dacryocystorhinostomy and Monocanalicular Intubation in Patients with Total Obstruction of One Canalicus

Purpose

We sought to evaluate the outcomes of external dacryocystorhinostomy (DCR) and mono-canalicular intubation in patients with total obstruction of one canalicus.

Methods

Sixteen eyes of 16 patients with nasolacrimal duct obstruction and a single canaliculus obstruction who had undergone external DCR and monocanalicular intubation of the intact canaliculus were retrospectively included in the present study. The monocanalicular tube (Mini Monoka) was left in place for at least two months. Munk epiphora grading for the evaluation of epiphora and irrigation was performed both preoperatively and at 6 months postoperatively.

Results

Mean patient age was 46 ± 14.2 (range, 18 to 76) years. The inferior canaliculus was obstructed in nine eyes (group A) and the superior canaliculus was obstructed in seven eyes (group B), respectively. Eight eyes had chronic dacryocystitis and two of these eyes also had a history of acute dacryocystitis attack. Mean preoperative Munk scores were 3.89 in group A and 4.0 in group B. Ocular surface irritation occurred in one eye in group A. Artificial eye drops were prescribed and early tube removal was not performed. Spontaneous tube dislocation was recorded in one eye in group B. No other corneal, punctal, or canalicular complications were found. At six months, irrigation of intact canaliculus was patent in all eyes. Mucoid discharge, conjunctival hyperemia, and chronic conjunctivitis were also resolved. Postoperative Munk scores were 1.11 ± 0.9 in group A and 0.86 ± 0.9 in group B. Of note, preoperative and postoperative Munk scores were significantly different in both groups (group A, p = 0.006; group B, p = 0.017). The postoperative Munk scores were not statistically different between the two groups (p = 0.606).

Conclusions

In patients with nasolacrimal duct obstruction and a total of one canaliculus obstruction, external DCR and monocanalicular intubation of the intact canaliculus is an effective surgical option.

Trends in conjunctivochalasis research from 1986 to 2017: A bibliometric analysis

BACKGROUND

With the aging of the population and the use of video terminals, the incidence of Conjunctivochalasis is getting higher, and related research is increasing. So our research aimed to use visualization software to display the research trends of Conjunctivochalasis.

METHODS

Retrieved the document (from 1986 to 2017) of conjunctivochalasis in the web of science core collection, analyzed by Citespace V.

RESULTS

The main language is English. Article is the key type of document. The average annual number of publications in the time period from 2008 to 2017 was 11.6, which was significantly higher than the period from 1994 to 2007, indicating that the total number of publications has been continuously developed. The law of frequency quoted showed an upward trend yearly. Furthermore, we can find out that Japan, USA, and People's Republic of China were the most productive countries, Kyoto Prefectural University of Medicine was the most prolific institution, Shanghai Jiaotong University is a key institution. The average IF of journals was 3.0508. Cornea and Canadian Journal of Ophthalmology are core journals. Tseng SCG is the most active scholar. All cited author contributed to 5 classifications. Di PMA paper is a classic literature. Huang YK paper can be regarded as the frontier document. All cited-reference dedicated to 7 categories. Conjunctivochalasis is the hot topic, related to observe indicators, risk factors, treatment, graded diagnosis of conjunctivochalasis, etc. In addition, fibroblast was research hotspot. At length, the cluster map of keyword was divided into 7 categories.

CONCLUSION

This research will help relevant clinicians and researchers to accurately and quickly grasp the research trends in the field, and continue to conduct new research on the basis.

Lipid Supplements and Clinical Aspects of Tear Film in Habitual Lens Wearers

PURPOSE

To establish the effect of lipid supplements on the tear lipid layer and their influence on lens wear comfort in habitual lens wearers.

METHODS

Forty habitual soft contact lens wearers were recruited to a double-masked, randomized crossover trial. An emulsion drop containing phosphatidylglycerine (Systane Balance; Alcon) and a saline drop as a placebo or a liposomal spray containing phosphatidylcholine (Tears again; BioRevive) and a saline spray as a placebo were used three times a day for 2 weeks with 48 hours washout between each intervention. Ocular comfort, lipid layer grade, and stability of the tear film using a Tearscope and tear evaporation rate using a modified VapoMeter were assessed after 6 hours of lens wear with lenses in situ.

RESULTS

Neither of the lipid supplements improved lens wear comfort compared to baseline. The noninvasive surface drying time significantly reduced with the placebo spray at day 1 (P = .002) and day 14 (P = .01) whereas the lipid spray had no effect. With the lipid drop and placebo, noninvasive surface drying time was unchanged compared to baseline (P > .05) on day 1, but by day 14, noninvasive surface drying time was reduced with the lipid drop (P = .02) and placebo (P < .001). Symptomatic wearers showed shorter noninvasive surface drying time compared to asymptomatic wearers with the spray treatment on both days (P = .03) but not with the lipid drop (P = .64). The placebo drop significantly changed the lipid layer distribution (P = .03) with a higher percentage of thinner patterns compared to the baseline distribution at day 14. A weak but significant correlation was shown between ocular comfort and noninvasive surface drying time (r = -0.21, P = .003) and tear evaporation rate (r = 0.19, P = .008). Ocular comfort was not associated with lipid layer patterns (r = 0.13, P = .06).

CONCLUSIONS

Ocular comfort during contact lens wear improved with increased tear film stability and a reduced tear evaporation rate. However, the lipid supplements did not improve ocular comfort from baseline.

Corneal Sensitivity and Inflammatory Biomarkers in Contact Lens Discomfort

PURPOSE

The aim of this study was to analyze whether symptoms of discomfort in hydrogel contact lens (HCL) wearers were associated with changes in corneal sensitivity or levels of tear inflammatory mediators.

METHODS

Sixty-six subjects were included: 47 HCL wearers, further divided into 24 symptomatic and 23 asymptomatic wearers by the Contact Lens Dry Eye Questionnaire short form and 19 non-contact lens wearers. At least 24 h after HCL removal, we obtained scores from the Ocular Surface Disease Index and mechanical, hot, and cold corneal thresholds using a Belmonte esthesiometer. We collected 4 μl of tears with a capillary micropipette and measured levels of 12 inflammatory markers using a bead-based array: epidermal growth factor, fractalkine, interleukin-10 (IL-10), IL-1β, IL-1 receptor antagonist, IL-2, IL-4, IL-6, IL-8, monocyte chemoattractant protein 1, tumor necrosis factor-α, and matrix metalloproteinase 9.

RESULTS

There were no significant differences between groups in corneal sensitivity thresholds and levels of tear molecules. The following significant correlations were found in the total sample pooled: Ocular Surface Disease Index correlated with mechanical threshold (p < 0.01; rho = -0.324) and epidermal growth factor (p < 0.01, rho = -0.330), and mechanical threshold correlated with heat threshold (p < 0.01, rho = -0.321).

CONCLUSIONS

Twenty-four hours after HCL removal, symptoms of discomfort in HCL wearers are not related to changes in corneal sensitivity or tear inflammatory mediator levels. This might indicate either that HCL wear has no effect on these parameters or that ocular surfaces recover from HCL-caused effects during the first hours after HCL removal. However, there were correlations for associations between symptoms, corneal sensitivity, and some molecules in tears.

Paradigm shifts, peregrinations and pixies in ophthalmology

Human ingenuity is challenged by defending vision, our highest bandwidth sense. Special challenges are presented by the replacement or repair of highly specialized but scarce tissue within the constraints of transparency, tissue shape and alignment, tissue borders and pressure maintenance. Many, mostly destructive, surgical procedures were developed prior to an understanding of underlying pathophysiology. For a number of conditions, both reconstructive and destructive procedures co-exist, yet there are few guidelines as to the better approach. Because the consequences of these procedures may take many years to surface (consistent with a stem cell role in long-term tissue maintenance), guidance may be provided by the elucidation of underlying principles from these approaches. Illustrative examples from clinical, basic research and biotechnology, particularly relating to pterygium, ocular surface squamous neoplasia, dry-eye syndrome, corneal rehabilitation and replacement, cataract surgery, strabismus surgery and bionic eye research, are described. An unexpected consequence of bionic device development has been an appreciation of the sophistication of tissues being replaced, given the limitations of available biomaterials. Examples of how this has provided insights into ocular disease will be illustrated. Stem cell and biomaterial technologies are starting to impact at a time when cost-effectiveness is under scrutiny. Both efficacy and cost will need to be considered as these interventions are introduced. It appears that the paradigm shift rate is accelerating and there is evidence of this in ophthalmology. Lessons learned from the areas of destructive versus reconstructive surgery and the limitations of development of bionic replacements will be used to illustrate how new procedures and technologies can be developed.

Enhanced Tearing by Electrical Stimulation of the Anterior Ethmoid Nerve

Purpose

Electrical neurostimulation enhances tear secretion, and can be applied to treatment of dry eye disease. Using a chronic implant, we evaluate the effects of stimulating the anterior ethmoid nerve on the aqueous, lipid, and protein content of secreted tears.

Methods

Neurostimulators were implanted beneath the nasal mucosa in 13 New Zealand white rabbits. Stimulations (2.3-2.8 mA pulses of 75-875 μs in duration repeated at 30-100 Hz for 3 minutes) were performed daily, for 3 weeks to measure changes in tear volume (Schirmer test), osmolarity (TearLab osmometer), lipid (Oil-Red-O staining), and protein (BCA assay, mass spectrometry).

Results

Stimulation of the anterior ethmoid nerve in the frequency range of 30 to 90 Hz increased tear volume by 92% to 133% (P ≤ 0.01). Modulating the treatment with 50% duty cycle (3 seconds of stimulation repeated every 6 seconds) increased tear secretion an additional 23% above continuous stimulation (P ≤ 0.01). Tear secretion returned to baseline levels within 7 minutes after stimulation ended. Tear film osmolarity decreased by 7 mOsmol/L, tear lipid increased by 24% to 36% and protein concentration increased by 48% (P ≤ 0.05). Relative abundance of the lacrimal gland proteins remained the same, while several serum and corneal proteins decreased with stimulation (P ≤ 0.05).

Conclusions

Electrical stimulation of the anterior ethmoid nerve increased aqueous tear volume, reduced tear osmolarity, added lipid, and increased the concentration of normal tear proteins. Human studies with an intranasal stimulator should verify these effects in patients with aqueous- and lipid-deficient forms of dry eye disease.

Corneal sensitivity, ocular surface health and tear film stability after punctal plug therapy of aqueous deficient dry eye

AIM

To evaluate the effect of punctal occlusion using thermosensitive (smart plug) versus silicone plug for management of aqueous deficient dry eye on corneal sensitivity, ocular surface health and tear film stability.

METHODS

A comparative prospective interventional case study included 45 patients with bilateral severe form of aqueous deficient dry eye. In each patient, the smart plug was inserted in the lower punctum of the right eye which was considered as study group 1 and silicone plug was inserted in the lower punctum of the left eye of the same patient which was considered as study group 2. All patients were subjected to careful history taking and questionnaire for subjective assessment of severity of symptoms. Corneal sensitivity, corneal fluorescein, rose bengal staining, Schirmer's I test, tear film break up time and conjunctival impression cytology were performed pre and 1, 3 and 6mo post plug insertion.

RESULTS

A statistically significant improvement in subjective and objective manifestations occurred following treatment with both types of plugs (P<0.01). The thermosensitive plug caused significant overall improvement, decrease in frequency of application of tear substitutes and improvement of conjunctival impression cytology parameters in the inserted side (P<0.01). Canaliculitis was reported in two eyes (4.4%) following punctal occlusion using thermosensitive plug (study group 1). Spontaneous plug loss occurred in 21 eyes (46.6%) in the silicone plug group (study group 2).

CONCLUSION

Improvement of subjective and objective manifestations of aqueous deficient dry eye occurs following punctal plug occlusion. Thermosensitive plug has good patient's compliance with fewer complications and lower rates of loss compared to the silicone plug.

Comprehensive Review of the Literature on Existing Punctal Plugs for the Management of Dry Eye Disease

Numerous designs of punctal and canalicular plugs are available on the market. This variety presents challenges to ophthalmologists when choosing punctal plugs for the management of various ocular conditions. The aim of this literature review is to provide a classification system for lacrimal occlusive devices based on their location and duration of action as well as to identify different characteristics of each one of them. We want to give a comprehensive overview on punctal and canalicular plugs including their manufacturing companies, indications, and complications that have been reported in various articles. PubMed and Google Scholar were used to identify articles written in English as well as few articles written in Japanese, Chinese, Slovak, and Spanish that had abstracts in English. Nine different companies that manufacture punctal and canalicular plugs were identified and their plugs were included in this review. Punctal and canalicular plugs are used in the management of various ocular conditions including dry eye disease and punctal stenosis as well as in ocular drug delivery. Although they are a relatively safe option, associated complications have been reported in the literature such as infection, allergic reaction, extrusion, and migration.

Effects of Punctal Occlusion on Clinical Signs and Symptoms and on Tear Cytokine Levels in Patients with Dry Eye

PURPOSE

To investigate changes in signs, symptoms, and tear cytokines following punctal plug occlusion in patients with dry eye.

METHODS

A single-center study was conducted at Singapore Eye Research Institute. Nonabsorbable punctal plugs were inserted in the lower punctum of both eyes in patients with moderate dry eye. Over 3 weeks, in the more severe eye, dry eye symptoms, fluorescein corneal staining, Schirmer I (without topical anesthesia) test, tear film breakup time (TFBUT), and safety were assessed. Cytokine and matrix metalloproteinase-9 (MMP-9) levels in tear samples were measured.

RESULTS

Twenty-nine patients (mean age 49.8 years) with moderate dry eye were evaluated. At baseline, mean (standard deviation) global symptoms score was 53.8 (26.5), Schirmer I test score was 5.1 (2.8) mm, and TFBUT was 2.2 (0.6) seconds. After 3 weeks, punctal occlusion significantly reduced global irritation symptoms score (P<.001) and decreased fluorescein staining in all zones (P<.01) except the inferior zone (P=.42). No significant association between levels of cytokines or MMP-9 and either TFBUT or global irritation symptoms were observed at baseline. Levels of several cytokines and MMP-9 were higher in patients with Schirmer I test scores ≤8 mm at baseline. After 3 weeks of punctal occlusion, no significant changes in overall cytokine or MMP-9 levels were observed.

CONCLUSIONS

Punctal plug occlusion provided symptomatic relief and reduced fluorescein staining in all except the inferior zone. However, insertion of punctal plugs had minimal effect on tear cytokines and MMP-9 levels, suggesting a need for earlier treatment with anti-inflammatory agents for management of dry eye disease.

Comparison of Topical Cyclosporine and Diquafosol Treatment in Dry Eye

PURPOSE

To compare the treatment effects of topical cyclosporine A (CsA) and diquafosol sodium (DQS) for the treatment of moderate to severe dry eye disease (DED).

METHODS

This prospective, nonrandomized, comparative study involved 60 eyes of 60 patients with moderate to severe DED who were treated with topical CsA 0.05% (group 1, 31 patients) or DQS 3% (group 2, 29 patients) in addition to artificial tears for 3 months. Before treatment, and at 1 and 3 months after treatment, the Ocular Surface Disease Index, tear breakup time, Schirmer score, tear clearance rate, and corneal and conjunctival staining scores were compared.

RESULTS

Significant improvements in Ocular Surface Disease Index score, tear clearance rate, and corneal staining score were observed 1 month after treatment in group 2 (p = 0.014, p = 0.002, and p < 0.001, respectively), when compared with group 1. However, no significant differences were observed between the two groups 3 months after treatment (p > 0.05). Tear breakup times were significantly higher in group 2 compared with group 1 for the duration of the study (p < 0.001). Three months after treatment, Schirmer score was significantly higher and conjunctival staining score was significantly lower in group 1 compared with group 2 (p < 0.001).

CONCLUSIONS

Both topical CsA 0.05% and DQS 3% are effective in patients with moderate to severe DED. However, the timing and degree of therapeutic effects on tear film and ocular surface parameters, as well as symptoms, can be different between the two treatments.

Diffusion tensor magnetic resonance imaging of trigeminal nerves in relapsing herpetic keratouveitis

Background

Corneal hypoesthesia is the landmark of HSV and VZV keratitis and can lead to neurotrophic keratitis. Diffusion tensor imaging (DTI) is a new magnetic resonance imaging (MRI) derived technique, which offers possibilities to study axonal architecture. We aimed at assessing the potential impact of recurrent HSV or VZV-related keratitis on the axonal architecture of trigeminal nerves using DTI.

Design

Prospective non-interventional study.

Participants

Twelve patients and 24 controls.

Methods

DTI using MRI of the trigeminal fibers and corneal esthesiometry using the Cochet-Bonnet esthesiometer were acquired for patients affected by unilateral and recurrent HSV or VZV-related keratitis (3 months after the last corneal inflammatory event), and control subjects with no history of ocular or neuronal disease affecting the trigeminal pathways.

Main Outcome Measures

Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were compared between the 2 eyes of both patients and controls, and correlated with corneal esthesiometry.

Results

FA was lower in the trigeminal fibers ipsilateral to the affected eye compared to the non-affected side (0.39±0.02 versus 0.46±0.04, P=0.03). This difference was more important than the intra-individual variability observed in controls. Concomitantly, the asymmetry in ADC results was significantly correlated with the loss of corneal sensitivity in the affected eye.

Conclusions

Corneal hypoesthesia related to HSV and VZV keratitis is associated with persistent modifications in the architecture and functionality of the trigeminal fibers. These results add further explanation to the pathogenesis of HSV and VZV-induced neurotrophic keratitis, which may occur despite an apparent quiescence of the disease.

New method for evaluation of early phase tear clearance by anterior segment optical coherence tomography

PURPOSE

To describe a new method of measuring early phase tear clearance by anterior segment optical coherence tomography (AS-OCT).

METHODS

Sixty normal subjects were divided into a young group (30 subjects; 29.6 ± 7.2 years) and an elder group (30 subjects; 71.4 ± 10.8 years). AS-OCT (CASIA SS-1000, Tomey, Japan) with customized software was used to record the tear meniscus at the centre of the lower eyelid. Five microlitres of lukewarm saline solution was dropped into the lower conjunctival sac, and an image of the tear meniscus was obtained immediately and again 30 seconds after natural blinking. The tear meniscus height (TMH) and tear meniscus area (TMA) were measured in the AS-OCT images, and the percentage decrease in the TMH and TMA was used as a measure of the tear clearance. Correlations between tear clearance and clinical features including degree of conjunctivochalasis, degree of protrusion of inferior lacrimal punctum, distance of lacrimal punctum from the Marx line and fluorescein clearance rates were also determined in another healthy population consisting of 30 subjects.

RESULTS

The OCT tear clearance rate was 35.2 ± 11% for TMH and 28.1 ± 12.4% for TMA in the young group, and 12.4 ± 7.3% and 6.2 ± 9.1%, respectively in the elder group. The differences were significant for both the TMH (p = 0.017) and the TMA (p = 0.024). The OCT-determined tear clearance was positively correlated with the fluorescein clearance rate, and negatively correlated with the distance between the lacrimal punctum and Marx line, degree of conjunctivochalasis and degree of lacrimal punctum protrusion.

CONCLUSION

AS-OCT can be used as a rapid, non-invasive and quantitative method of determining the early phase tear clearance rate in a normal healthy population.

Efficacy of punctal occlusion in management of dry eyes after laser in situ keratomileusis for myopia

PURPOSE

To evaluate the effect of punctal plug use in preventing dry eye after laser in situ keratomileusis (LASIK).

MATERIALS AND METHODS

A randomized clinical trial at a tertiary eye care center, Riyadh, Saudi Arabia. Participants underwent LASIK for myopia in both eyes and a lower punctal occlusion in one eye only while the other eye served as control. Both eyes received the same postoperative medications except for lubricant duration (subject eye: four times per day for one week; control eye: four times per day for 6 months). Participants were evaluated at 1 week, 2, and 6 months after surgery for signs and symptoms of dry eye. The main outcome measures were visual acuity; ocular surface parameters; and Ocular Surface Disease Index questionnaire.

RESULTS

Seventy-eight eyes of 39 patients were included in this study. The Ocular Surface Disease Index scores of eyes with punctal plugs were better at all follow-up visits, and the differences between both eyes were statistically significant (1 week, p < 0.0001; 2 months, p < 0.0001; 6 months, p = 0.008). At the final follow-up visit, the percentage of normal eyes was higher in eyes with punctal plugs for all ocular surface parameters (Schirmer 1 test, 94.9%; tear breakup time, 77.8%; punctate epithelial keratitis score, 71.8%) compared to eyes without occlusion (Schirmer 1 test, 92.3%; tear breakup time, 58.3%; punctate epithelial keratitis score, 53.8%); however, such differences were not statistically significant.

CONCLUSION

Punctal plug insertion after LASIK surgeries may minimize the need for frequent lubricant application and hence improve patient satisfaction.

The TFOS International Workshop on Contact Lens Discomfort: report of the subcommittee on neurobiology

This report characterizes the neurobiology of the ocular surface and highlights relevant mechanisms that may underpin contact lens-related discomfort. While there is limited evidence for the mechanisms involved in contact lens-related discomfort, neurobiological mechanisms in dry eye disease, the inflammatory pathway, the effect of hyperosmolarity on ocular surface nociceptors, and subsequent sensory processing of ocular pain and discomfort have been at least partly elucidated and are presented herein to provide insight in this new arena. The stimulus to the ocular surface from a contact lens is likely to be complex and multifactorial, including components of osmolarity, solution effects, desiccation, thermal effects, inflammation, friction, and mechanical stimulation. Sensory input will arise from stimulation of the lid margin, palpebral and bulbar conjunctiva, and the cornea.

Emerging drugs for the treatment of dry eye disease

INTRODUCTION

Dry eye disease (DED) is a common, age-related ocular condition that in its mildest forms causes bothersome symptoms of ocular discomfort, fatigue, and visual disturbance that interfere with quality of life and in its more severe forms causes chronic pain and fluctuating vision. Though it is highly prevalent and costs billions of dollars to manage, current treatments have largely been inadequate, making it a frustrating condition, both for physicians and patients alike.

AREAS COVERED

This article will cover the recently discovered pathophysiology of DED that has prompted investigators to explore new molecules that target the core mechanisms that drive DED. These include anti-inflammatory/immune-modulatory drugs, secretagogues, lubricant, hormones, and autologous serum. Their potential mechanism of action and data from recent trials on efficacy/safety will be reviewed.

EXPERT OPINION

The emerging drugs have a vast range of putative mechanisms of action that may not only provide symptomatic relief but may potentially break the vicious cycle of DED and provide long-lasting cure. Current and future research may change our perspective on DED and redefine its treatment algorithms.

Tear meniscus measurement in nasolacrimal duct obstruction patients with Fourier-domain optical coherence tomography: novel three-point capture method

PURPOSE

Fourier-domain optical coherence tomography (FD ODT) for the evaluation of marginal tear film has not been performed in patients with watery eye or in a controlled study. We used FD OCT to evaluate the height of the lower lid tear film at three points in normal adults and compared it with two watery eye groups.

METHODS

We prospectively evaluated with FD OCT 25 normal subjects and 44 patients with a watery eye. Twenty-three patients with primary acquired nasolacrimal duct obstruction (PANDO) and 21 patients with functional nasolacrimal duct obstruction (FNLDO) were enrolled. Three images were obtained by three vertical FD OCT scans centred on the lower eyelid and inferior cornea, the medial limbus and the lateral limbus. The tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus area (TMA) were measured with computer calipers and compared at three points between the two groups.

RESULTS

Watery eyes have significantly greater median TMHs at three points (medial: 584 μm, central: 592 μm, lateral: 470 μm) than controls (274, 291, 205 μm, p < 0.001). Medial and central TMHs were higher than lateral TMH in controls and watery eyes. TMD and TMA also increased significantly in watery eyes (p < 0.001). There was a significant increase in central TMH compared to medial TMH in FNLDOs than in PANDOs (p < 0.05).

CONCLUSION

Fourier-domain OCT is a valuable clinical tool in the evaluation of TMH in normal and watery eyes. TMH at three points can be a useful clinical parameter that investigates changes of lower tear meniscus pattern in both PANDO and FNLDO groups.

Evaluation of dry eye

Dry eye is a common yet complex condition. Intrinsic and extrinsic factors can cause dysfunction of the lids, lacrimal glands, meibomian glands, ocular surface cells, or neural network. These problems would ultimately be expressed at the tear film-ocular surface interface. The manifestations of these problems are experienced as symptoms such as grittiness, discomfort, burning sensation, hyperemia, and secondary epiphora in some cases. Accurate investigation of dry eye is crucial to correct management of the condition. Techniques can be classed according to their investigation of tear production, tear stability, and surface damage (including histological tests). The application, validity, reliability, compatibility, protocols, and indications for these are important. The use of a diagnostic algorithm may lead to more accurate diagnosis and management. The lack of correlation between signs and symptoms seems to favor tear film osmolarity, an objective biomarker, as the best current clue to correct diagnosis.

An overview on dry eye treatment: approaches for cyclosporin a delivery

Dry eye syndrome (DES, Keratoconjunctivitis sicca) is a common disorder of the tear film caused by decreased tear production or increased evaporation. Changes in tear composition also promote inflammation on the ocular surface by various mechanisms. Artificial tear drops, tear retention treatment, stimulation of tear secretion, or anti-inflammatory drugs may be used for dry eye treatment according to the severity of the disease. For untreated patients, the risk of ocular infection increases at considerable level and clinical course of the disease may proceed up to infection, corneal ulcer, and blindness. Artificial tears and/or punctual occlusions are used for tear replacement or preservation. New treatment approaches are designed to modify the underlying disease process. For the treatment of severe dry eye disease, cyclosporin A (CsA), the first one of the new generation immunomodulatory drugs, which has an anti-inflammatory effect, is frequently used. CsA has immunosuppressive effects following systemic application. Following local administration of CsA, it is expected to obtain effective drug concentration at the target area and to avoid the various side effects associated with systemic delivery. Microspheres, implants, and liposomes have been developed for administration of CsA subconjunctivally in order to enhance its efficiency.

Review of hydroxypropyl cellulose ophthalmic inserts for treatment of dry eye

Dry eye syndrome is a prevalent disease that affects visual acuity, activities of daily living, and quality of life. A number of contributory factors affect the severity of dry eye syndrome, including autoimmune disease, environmental surroundings, contact lens use, hormonal changes, anatomical features, chronic inflammation, infections, and iatrogenic factors, such as medications or surgery. Symptoms may include intermittent or constant blurry vision, discomfort, burning, foreign body sensation, hyperemia, dryness, and photophobia. The severity of dry eye syndrome can range from very mild disease to extremely severe cases with vision-threatening consequences. A variety of dry eye treatment modalities exist to address the different causes, symptoms, and consequences of ocular surface disease, including artificial tears, lubricating gels, ophthalmic inserts, anti-inflammatory drops, and surgical procedures. In this paper, an assortment of literature pertaining to the treatment of dry eye syndrome, in particular hydroxypropyl cellulose ophthalmic inserts, is reviewed. These inserts can be used effectively as monotherapy, or in conjunction with other therapies, and should be considered in the treatment of dry eye syndrome.

Surgical punctal occlusion with a high heat-energy releasing cautery device for severe dry eye with recurrent punctal plug extrusion

PURPOSE

To report the rate of recanalization and the efficacy of punctal occlusion surgery with a high heat-energy-releasing cautery device in patients with severe dry eye disease and recurrent punctal plug extrusion.

DESIGN

Prospective, interventional case series.

METHODS

Seventy puncta from 44 eyes of 28 dry eye patients underwent punctal occlusion with thermal cautery. All patients had a history of recurrent punctal plug extrusion. A high heat-energy-releasing thermal cautery device (Optemp II V; Alcon Japan) was used for punctal occlusion surgery. Symptom scores, best-corrected visual acuity, fluorescein staining score, rose bengal staining score, tear film break-up time, and Schirmer test values were compared before and 3 months after the surgery. Rate of punctal recanalization also was examined.

RESULTS

Three months after surgical cauterization, symptom score decreased from 3.9 ± 0.23 to 0.56 ± 0.84 (P < .0001). Logarithm of the minimal angle of resolution best-corrected visual acuity improved from 0.11 ± 0.30 to 0.013 ± 0.22 (P = .003). Fluorescein staining score, rose bengal staining score, tear film break-up time, and the Schirmer test value also improved significantly after the surgery. Only 1 of 70 puncta recanalized after thermal cauterization (1.4%).

CONCLUSIONS

Punctal occlusion with the high heat-energy-releasing cautery device not only was associated with a low recanalization rate, but also with improvements in ocular surface wetness and better visual acuity.

Transconjunctival incision for total maxillectomy--an alternative for subciliary incision

A subciliary incision may be associated with various complications of the lower eyelid when it is used during a total maxillectomy. The use of the transconjunctival incision instead is an alternative in suitable patients. The records of 17 patients were reviewed in whom a transconjunctival incision was used during total maxillectomy. These included 13 in whom the Weber-Ferguson incision was used, and 4 who had a sublabial incision. There was mild conjunctival oedema in all the cases during the immediate postoperative period but it did not last for more than two days. Four patients had mild to moderate oedema of the lid that resolved within two days. One had mild ectropion with transient epiphora, which was caused by early removal of the medial canthal sutures. We found the approach to be cosmetically acceptable as it avoids a scar in the subciliary region. The transconjunctival incision can be used in place of the subciliary incision for lateral exposure during total maxillectomy. There are few complications associated with the lower lid, and it has good cosmetic results; if it is combined with a sublabial incision in suitable patients, the maxillectomy is virtually scar-free.

Advancements in anti-inflammatory therapy for dry eye syndrome

PURPOSE

The goal of this literature review is to discuss recent discoveries in the pathophysiology of dry eye and the subsequent evolution of diagnostic and management techniques. The mechanisms of various anti-inflammatory treatments are reviewed, and the efficacy of common pharmacologic agents is assessed. Anti-inflammatory therapy is evaluated in terms of its primary indications, target population, and utility within a clinical setting.

METHODS

The Medline PubMed database and the World Wide Web were searched for current information regarding dry eye prevalence, pathogenesis, diagnosis, and management. After an analysis of the literature, major concepts were integrated to generate an updated portrayal of the status of dry eye syndrome.

RESULTS

Inflammation appears to play a key role in perpetuating and sustaining dry eye. Discoveries of inflammatory markers found within the corneal and conjunctival epithelium of dry eye patients have triggered recent advancements in therapy. Pharmacologic anti-inflammatory therapy for dry eye includes 2 major categories: corticosteroids and immunomodulatory agents. Fatty acid and androgen supplementation and oral antibiotics have also shown promise in dry eye therapy because of their anti-inflammatory effects.

CONCLUSIONS

Anti-inflammatory pharmacologic agents have shown great success in patients with moderate to severe dry eye when compared with alternative treatment modalities. A deeper understanding of the link between inflammation and dry eye validates the utilization of anti-inflammatory therapy in everyday optometric practice.

Tear Dynamics Model

PURPOSE

Quantitative understanding of tear dynamics may help in developing better ophthalmic drug delivery vehicles and dry eye treatments. This paper attempts to develop a comprehensive model that can predict the effect of physiological parameters on various issues related to tear dynamics.

METHODS

The model is based on mass balances of water and solutes such as glucose, sodium, potassium, and chloride. The mass balances require models for the drainage of fluid through the canaliculi and the transport of tears and solutes through the conjunctiva. The model parameters are obtained by simulating Ussing-chamber experiments. The differential equations for the unsteady balances are solved numerically.

RESULTS

The model predicts that under normal conditions, the tear volume, tear osmolarity and potential are 7.1 microl, 297.6 mM, and -15.1 mV, respectively. The model also predicts that the conjunctiva is secretory and contributes about 25% of the total tear production. We also predict the effect of evaporation on tear physiology and show that an increase in evaporation increases osmolarity, reduces tear volume, and increases conjuctival secretion. Additionally, the new tear dynamics model helps assess the effect of osmolarity of the instilled drops, insertion of punctum plugs and use of moisture chamber as treatments for dry eyes. Furthermore, the model is used to predict the effect of modulation of specific transport pathways, which is proposed as a potential remedy for dry eyes, on conjuctival secretion and total tear volume.

CONCLUSIONS

Most of the predicted results agree with the reported experimental results, at least qualitatively. However, some predictions disagree with experiments suggesting that further improvements in the model are needed. The model developed in this paper can improve our understanding of tear dynamics and also serve as a tool to evaluate the efficacy of various modalities at treating dry eyes.

The impact of punctal occlusion on soft contact lens wearing comfort and the tear film

OBJECTIVES

The purpose of this report is to describe the impact of punctal occlusion in symptomatic dry eye contact lens wearers and the relation between subjective and objective outcomes.

METHODS

This study was a randomized, controlled, double-masked, single center clinical trial. A previously described dry-eye questionnaire was used to determine subject eligibility. Tear interferometry was performed to evaluate prelens tear film thickness, contact lens center thickness, and postlens tear film thickness. Each subject was randomly assigned to receive the punctal plugs or a sham procedure. At the outcome examination, the subject completed the dry-eye questionnaire and answered one question rating the efficacy of the punctal plug treatment in addition to undergoing tear interferometry using an identical protocol as the first visit.

RESULTS

Nineteen subjects completed both visits of this study. There was a significant improvement in the dry-eye questionnaire scores from baseline to the outcome visit for both the plug (Z = -2.52, P=0.01) and sham groups (Z = -2.93, P=0.003). A significant increase in prelens tear film thickness occurred within the sham group from baseline to the outcome visit (Z = -1.96, P=0.05), but not for the punctal plug group. No other layers measured by interferometry were shown to change significantly for either group.

CONCLUSIONS

Results comparing the sham and plug groups were not significantly different from each other with regards to the questionnaire score and treatment benefit assessment, indicating either the treatment effect was not detected, although present, or punctal occlusion had no treatment effect at all.

Effects of upper eyelid blepharoplasty on ocular surface sensation and tear production

BACKGROUND

To evaluate the effect of upper eyelid surgery on ocular surface sensation and tear production.

METHODS

Prospective, interventional, consecutive case series. Patients undergoing upper eyelid blepharoplasty or blepharoptosis repair were evaluated with measurements of their corneal sensation and tear production using a Cochet-Bonnet esthesiometer and the Schirmer 1 test without anesthesia, respectively. Measurements were obtained preperatively, and at 1 day and 1 month postoperatively.

RESULTS

Eleven patients (21 eyes) were enrolled in the study. There was a significant decrease in corneal sensation between the baseline and postperative day 1 (p < 0.01) and a significant increase between day 1 and month 1 after surgery (p < 0.01). There was no statistically significant difference in corneal sensation between the baseline and postoperative 1 month measurement (p > 0.05). There was no significant difference in tear production between baseline and postoperative day 1 (p > 0.05). There was a statistically significant increase in tear production between baseline and postoperative month 1 (p < 0.05). There was no significant correlation between corneal sensitivity and Schirmer 1 test preoperatively, at postoperative day 1, or at postoperative month 1 after surgery.

INTERPRETATION

Upper eyelid surgery results in a temporary decrease in ocular surface sensation that returns to baseline after 1 month. Patients with pre-existing ocular surface dysfunction should consider aggressive treatments with lubricating drops and ointment, punctual occlusion, or anti-inflammatory therapy to accommodate the temporary effects on ocular surface sensation that result from upper eyelid surgery.