Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment

Experimental interventions attenuate a conjunctival epidermal metaplasia model

The conjunctiva is a non-keratinized, stratified columnar epithelium with characteristics different from the cornea and eyelid epidermis. From development to adulthood, a distinguishing feature of ocular versus epidermal epithelia is the expression of the master regulator PAX6. A conditionally immortalized conjunctival epithelial cell line (iHCjEC) devoid of stromal or immune cells established in our laboratory spontaneously manifested epidermal metaplasia and upregulated expression of the keratinization-related genes SPRR1A/B and the epidermal cytokeratins KRT1 and KRT10 at the expense of the conjunctival trait. In addition, iHCjEC indicated a significant decrease in PAX6 expression. Dry eye syndrome (DES) and severe ocular surface diseases, such as Sjögren's syndrome and Stevens-Johnson syndrome, cause the keratinization of the entire ocular surface epithelia. We used iHCjECs as a conjunctiva epidermal metaplasia model to test PAX6, serum, and glucocorticoid interventions. Reintroducing PAX6 to iHCjECs resulted in upregulating genes related to cell adhesion and tight junctions, including MIR200CHG and CLDN1. The administration of glucocorticoids or serum resulted in the downregulation of epidermal genes (DSG1, SPRR1A/B, and KRT1) and partially corrected epidermal metaplasia. Our results using an isolated conjunctival epidermal metaplasia model point toward the possibility of rationally "repurposing" clinical interventions, such as glucocorticoid, serum, or PAX6 administration, for treating epidermal metaplasia of the conjunctiva.

The role of topical insulin on ocular surface restoration: A review

Corneal epithelial defects are one of the most common ocular disorders.Restoring corneal integrity is crucial to reduce pain and regain function,but in cases of neurotrophic or desensitized corneas,healing can be significantly delayed.Treating neurotrophic corneas is challenging for ophthalmologists,and surgical intervention is often indicated to manage refractory cases that are unresponsive to medical therapy.Over the last decade,as more expensive therapeutics reach the market,topical insulin has returned to the forefront as an affordable option to improve corneal wound healing.There is still a paucity of data on the use and the efficacy of topical insulin,with no consensus regarding its indications,preparation,or posology.Here we review the literature on topical insulin for corneal and ocular surface pathologies,with a focus on the current evidence,its mechanisms of action,and its safety profile.Additionally,we share our experience in the field and provide a potential framework for future research.

Mucoadhesive, antioxidant, and lubricant catechol-functionalized poly(phosphobetaine) as biomaterial nanotherapeutics for treating ocular dryness

Dry eye disease (DED) is associated with ocular hyperosmolarity and inflammation. The marketed topical eye drops for DED treatment often lack bioavailability and precorneal residence time. In this study, we investigated catechol-functionalized polyzwitterion p(MPC-co-DMA), composed of 2-methacryloyloxyethyl phosphorylcholine (MPC) and dopamine methacrylamide (DMA) monomers, as potential topical nanotherapeutics for DED. The copolymers were synthesized via random free-radical copolymerization, producing different proportions of catecholic functionalization. All as-prepared polymer compositions displayed good ocular biocompatibility. At a feeding ratio of 1:1, p(MPC1-co-DMA1) can facilitate a robust mucoadhesion via Michael addition and/or Schiff base reaction, thus prolonging ocular residence time after 4 days of topical instillation. The hydration lubrication of MPC and radical-scavenging DMA endow the nano-agent to ease tear-film hyperosmolarity and corneal inflammation. A single dose of p(MPC1-co-DMA1) (1 mg/mL) after 4 days post-instillation can protect the cornea against reactive oxygen species, inhibiting cell apoptosis and the over-expression of pro-inflammatory factors (IL-6 and TNF-α). In clinical assessment, DED-induced rabbit eyes receiving p(MPC1-co-DMA1) could increase lacrimal fluid secretion by 5-fold higher than cyclosporine A. The catechol-functionalized polyzwitterion with enhanced lubricity, mucoadhesion, and anti-oxidation/anti-inflammation properties has shown high promise as a bioactive eye drop formulation for treating DED.

Is Meibomian Gland Dysfunction One Disease? Heterogeneity Among Phenotypes

PURPOSE

The purpose of this study was to examine ocular surface symptoms, tear metrics, and tear cytokines by Meibomian gland dysfunction (MGD) features.

METHODS

Symptom questionnaires and an ocular surface evaluation were performed on 40 individuals with varied MGD signs [Meibomian gland (MG) plugging, eyelid vascularity, meibum quality, and MG dropout]. Tear proteins were extracted off Schirmer strips and analyzed for 23 human inflammation-related proteins. Statistical analysis was performed to examine associations between dry eye metrics inflammatory proteins and MGD features.

RESULTS

The study involved 40 South Florida veterans with a mean age of 61 ± 13 years; most individuals were male (95%), White (31%), and non-Hispanic (85%). MGD features differentially related to dry eye signs. Eyelid vascularity, meibum quality, and MG dropout, but not MG plugging, correlated with higher corneal staining and lower tear production. MGD features also differentially related to tear cytokines. Eyelid vascularity most closely related to inflammation with significant correlations for interferon-gamma-γ (r = 0.36, P = 0.02), interleukin-4 (IL-4) (r = 0.43, P = 0.006), IL-17A (r = 0.42, P = 0.007), matrix metalloproteinase-2 (r = 0.39, P = 0.01), C-X-C motif chemokine ligand 5 (Regulated upon Activation, Normal T-Cell Expressed and presumably Secreted [RANTES]) (r = 0.32, P = 0.04), and tumor necrosis factor α (r = 0.36, P = 0.02). The other 3 MGD signs were less related to inflammation. Multivariable models revealed IL-4 to be most closely related to eyelid vascularity (standardized β = 0.39, P < 0.0001).

CONCLUSIONS

Eyelid vascularity was the MGD sign most closely related to inflammatory cytokines, suggesting that different MGD features may be driven by different pathophysiological mechanisms.

Ocular surface lesions in clinical grades of Bell's phenomenon

Background

Bell's phenomenon, also known as the palpebral oculogyric reflex, is a critical reflex that protects the cornea. We developed an innovative, simple, and practical grading scale for Bell's phenomenon that includes the inverse Bell's phenomenon. Using this scale, we investigated the characteristics of Bell's phenomenon among asymptomatic individuals in different age groups and examined the frequency of ocular surface lesions in asymptomatic and symptomatic participants with different grades.

Methods

In this cross-sectional study, we randomly included 330 eyes of 165 asymptomatic, healthy, White Turkish individuals who attended the outpatient eye clinic, with a male-to-female ratio of 1:1.4, in the control group. These were categorized into four age groups: 4 - 20 years, 21 - 40 years, 41 - 60 years, and > 60 years. Eighty eyes from 40 patients with ocular surface lesions and absence of grade + 2 Bell's phenomenon were included in the symptomatic group. Bell's phenomenon was classified into five grades: grade + 2 (strong positive), grade + 1 (weak positive), grade 0 (no Bell's phenomenon, no eye movement), grade -1 (weak inverse), and grade -2 (strong inverse).

Results

We detected higher frequencies of grade + 2, + 1, and 0 in individuals aged 4 - 40, 41 - 60, and > 60 years, respectively. There was a significant difference between age groups in the frequencies of different grades (P < 0.001). Pairwise analysis revealed a significantly lower frequency of grade + 2 in the age group > 60 years compared with the 4 - 20 and 21 - 40 year groups (both P < 0.05). Grade + 2 was the most frequent in both sexes. We detected grade 0 in 27.1% of men and 22.1% of women in the control group, with no significant difference in the frequencies of different grades between sexes (P > 0.05). We observed significant differences between grades with respect to the frequency of ocular surface lesions (P < 0.001). Pairwise analysis revealed a significantly higher frequency of ocular surface lesions in asymptomatic individuals with grade 0 and all four other grades (all P < 0.001). However, the frequency of ocular surface lesions was comparable between sexes (P > 0.05). Of the 40 symptomatic individuals, 28 (70%), 5 (12.5%), 4 (10%), and 3 (7.5%) had grade 0, + 1, -1, and -2, respectively. The number of symptomatic patients was higher in grade 0 (n = 28) than in other grades (grade + 1, -1, and -2: n = 12 patients), and these individuals had a higher frequency of ocular surface lesions (n = 38 lesions) than others (grade + 1, -1, and -2: 7 lesions).

Conclusions

Using a simple, practical grading scale for Bell's phenomenon that includes inverse Bell's phenomenon, we observed that inverse Bell's phenomenon is a reflex that may be present in healthy individuals and could have a protective effect on the eye, although not to such a degree as a strong Bell's phenomenon. Our observations imply that bilateral conjunctival calcifications/Vogt's limbal girdle may be associated with grades 0 and + 1 Bell's phenomenon. Further large-scale studies are needed to determine the frequency of Bell's phenomenon in the general population using this innovative, simple, practical grading scale, and to identify the protective or injurious effect of each grade on the ocular surface.

Overview of CFTR activators and their recent studies for dry eye disease: a review

The cystic fibrosis transmembrane conductance regulator (CFTR) gets activated via the cAMP signaling pathway and is present in various secretory epithelial cells, including conjunctival and corneal epithelial cells. Activation of CFTR leads to fluid secretion in both mouse and human ocular surfaces. Dry eye disease is a significant health problem for which limited therapeutic options are available. In this review, on the one hand, small molecule CFTR activators with different chemical structures are summarized, and on the other hand, the pharmacological activity test and structural optimization of small molecule CFTR activators in the treatment of dry eye are outlined. The purpose of this review is to highlight the important role of CFTR activators in the treatment of dry eye disease and their potential as a new strategy for the treatment of dry eye disease.

The Molecular Mechanisms Responsible for Tear Hyperosmolarity-Induced Pathological Changes in the Eyes of Dry Eye Disease Patients

Dry eye disease (DED) is a multifactorial disorder of the lacrimal system and ocular surface, characterized by a deficiency in the quality and/or quantity of the tear fluid. The multifactorial nature of DED encompasses a number of interconnected underlying pathologies, including loss of homeostasis, instability and hyperosmolarity of the tears, and the induction and propagation of detrimental inflammatory responses in the eyes, which finally results in the development of neurosensory dysfunction and visual disruption. Dryness, grittiness, scratchiness, discomfort, inflammation, burning, watering, ocular fatigue, pain, and decreased functional visual acuity are common symptoms of DED. Eye dysfunction drastically attenuates patients' quality of life. Accordingly, a better understanding of the pathogenic processes that regulate the development and progression of DED is crucially important for the establishment of new and more effective DED-related treatment approaches, which would significantly improve the quality of life of DED patients. Since the process of osmoregulation, which guards the ocular surface epithelia and maintains normal vision, is affected when the osmolarity of the tears is greater than that of the epithelial cells, tear hyperosmolarity (THO) is considered an initial, important step in the development, progression, and aggravation of DED. In order to delineate the role of THO in the pathogenesis of DED, in this review article, we summarize current knowledge related to the molecular mechanisms responsible for the development of THO-induced pathological changes in the eyes of DED patients, and we briefly discuss the therapeutic potential of hypo-osmotic eye drops in DED treatment.

Role of lymphotoxin alpha as a new molecular biomarker in revolutionizing tear diagnostic testing for dry eye disease

Dry eye disease (DED), primarily classified as multifactorial ocular surface disorder, afflicts tens of millions of individuals worldwide, adversely impacting their quality of life. Extensive research has been conducted on tear film analysis over the past decades, offering a range of tests to evaluate its volume, health, and integrity. Yet, early diagnosis and effective treatment for DED continue to pose significant challenges in clinical settings. Nevertheless, by recognizing key phenomena in DED such as ocular surface inflammation, hyperosmolarity, and tear film instability, this article provides a comprehensive overview of both traditional and recently developed methods for diagnosing and monitoring DED. The information serves as a valuable resource not only for clinical diagnosis but also for further research into DED.

Glaucoma and Dry Eye Disease: Opportunity to Assess and Treat

Dry eye disease (DED) has been found to occur at a higher prevalence in individuals with glaucoma than in individuals without glaucoma. The relationship between glaucoma and DED may be, in part, a result of glaucoma therapy. Greater number of antiglaucoma medications used and greater number of antiglaucoma eyedrops instilled per day have been associated with ocular surface disease in patients with glaucoma. Use of antiglaucoma medication has also been associated with higher levels of ocular surface inflammatory markers and ocular surface alterations. There is evidence to suggest that antiglaucoma medications with preservatives and, to some extent, antiglaucoma medication formulations without preservatives may contribute to ocular surface signs and symptoms. Trabeculectomy for glaucoma has also been associated with ocular surface signs related to DED; however, there may be benefits of trabeculectomy and other procedures for glaucoma due to reduced use of antiglaucoma medications. Patients with glaucoma with ocular surface disease have been found to have greater ocular surface symptoms, poorer vision-related quality of life, and poorer antiglaucoma medication adherence compared with patients with glaucoma without ocular surface disease. Because of the potential negative impact of DED on patients with glaucoma, patients with glaucoma may benefit from evaluation for DED. Management of DED in patients with glaucoma may include modifications to antiglaucoma medications and use of treatments for DED.

Treatment of Demodex Blepharitis: A Prospective, Randomized, Controlled, Double-Masked Clinical Trial Comparing Topical Lotilaner Ophthalmic Solution, 0.25% Eyedrops to Vehicle

PURPOSE

To evaluate the efficacy and safety of lotilaner ophthalmic solution, 0.25% eyedrops compared to vehicle for the treatment of Demodex blepharitis.

METHODS

In this randomized, controlled, double-masked clinical trial, 54 participants were randomly assigned in a 1:1 ratio to receive either lotilaner ophthalmic solution, 0.25% (study group) or the vehicle (control group) bilaterally, twice daily for 42 days. Outcome measures were collarette cure (collarette grade 0, upper eyelid), mite eradication (mite density of 0 mites/lash), and composite cure (grade 0 for collarettes and erythema).

RESULTS

The proportion of participants achieving collarette cure (80.0% vs 15.8%; p < .001), mite eradication (73.3% vs 21.1%, p = .003) and composite cure (73.3% vs 10.5%, p < .001) at Day 42 was statistically significantly higher in the study group than the control group.

CONCLUSION

Twice-daily 42-day treatment with novel lotilaner ophthalmic solution, 0.25% is safe and effective for the treatment of Demodex blepharitis compared to the vehicle control. (Registry number: ACTRN12620000320954, dated 09/03/2020).

Safety and efficacy of intense pulsed light in the treatment of severe chronic ocular graft-versus-host disease

OBJECTIVE

To investigate the safety and efficacy of intense pulsed light (IPL) in the treatment of severe chronic ocular graft-versus-host disease (coGVHD).

METHODS

A prospective cohort study. Seventeen patients with severe coGVHD were selected for inclusion in this study. All subjects were treated with IPL every fortnight together with conventional treatment, observation time points were pre-treatment (W0), 4 weeks post-treatment (W4), 8 weeks post-treatment (W8) and 12 weeks post-treatment (W12). Dry eye related examinations include Tear meniscus height (TMH), Non-invasive break-up time (NIBUT), Schirmer I test, Tear film lipid layer thickness (LLT), Ocular surface staining (OSS) and assessment of meibomian gland. Corneal epithelial cell morphology and inflammatory cell infiltration were analyzed by corneal confocal microscopy, while goblet cell density and squamous epithelial grade were assessed by conjunctival imprinted cytology.

RESULTS

Patients did not experience any adverse reactions during the follow-up period. All subjects showed significant improvement in clinical symptoms and most signs after IPL treatment. The corneal confocal microscopy showed that the number of dendritic cells infiltrates in the corneal stroma was significantly reduced after IPL treatment (p < 0.001). Conjunctival blot cytology suggested an increase in the number of conjunctival goblet cells from 5.12 ± 2.71 cells/mm2 before treatment to 22.00 ± 4.58 cells/mm2 after treatment, with a statistically significant difference (p < 0.001). An improvement in conjunctival epithelial cell morphology and a decrease in squamous epithelial grade was also observed.

CONCLUSIONS

IPL treatment can effectively increase tear film stability in patients with severe coGVHD without significant side effects.

Rapid detection of tear lactoferrin for diagnosis of dry eyes by using fluorescence polarization-based aptasensor

Differentiating dry eye disease (DED) from allergic or viral conjunctivitis rapidly and accurately is important to ensure prompt diagnosis and treatment. Tear lactoferrin (LF), a multi-functional glycoprotein found in tears, decreases significantly in patients with DED, and has been considered as a DED diagnostic biomarker. Measuring tear LF level, however, takes time and requires the use of bulky instruments. Herein, a homogeneous carbon nanostructure-based aptasensor with high sensitivity and selectivity has been developed by applying fluorescence polarization (FP) technology. The FP of carbon dots (CDs) bioconjugated with LF aptamers (CDs-aptamer) is 21.2% higher than that of CDs, which can be further amplified (1.81 times) once interacting with graphene oxide nanosheets (GONS). In the presence of LF, GONS separates from CDs-aptamer because of the stronger binding affinity between CDs-aptamer to LF, resulting in the decrease of FP value. A linear relationship is observed between FP value and LF concentration in spiked tear samples from 0.66 to 3.32 mg/mL. The selectivity of the aptasensor has been investigated by measuring other proteins. The results indicate that the FP-based aptasensor is a cost-effective method with high sensitivity and selectivity in detection of tear LF.

Randomized comparison of in vivo performance of TearLab® and I-PEN® osmometry in normal dogs

OBJECTIVE

To compare tear film (TF) osmolarity measured using TearLab® and I-PEN® osmometers in the same dogs without any ocular surface disease.

ANIMAL STUDIED

Fifty-two dogs (98 eyes) of different breeds were evaluated.

PROCEDURES

Tear film (TF) osmolarity was evaluated at 2-min intervals. The test was randomly determined, and single measurements were performed using each osmometer. Subsequently, complete ophthalmologic examinations were performed based on Schirmer tear test-1 (STT-1) analysis, tear film breakup time (TFBUT), and slit-lamp biomicroscopy. For each osmometer, the mean ± standard deviation of the TF osmolarity was calculated, and a paired Student's t-test was used to compare the values obtained. Pearson correlation analysis was performed to assess the association between osmolarity and other values such as STT-1, TFBUT, and age.

RESULTS

Tear film osmolarity determined using TearLab® (340.42 ± 15.87 mOsm/L) and I-PEN® (321.58 ± 17.39 mOsm/L) were significantly different (p < .001). However, statistical significance could not be confirmed between osmolarity and other values, such as STT-1, TFBUT, and age.

CONCLUSIONS

In dogs, the TF osmolarity values obtained using TearLab® tend to be higher than those obtained using I-PEN®, contrary to that observed in humans. These findings can serve as a reference for establishing normal values for each osmometer for clinical use in measuring TF osmolarity in dogs.

Efficacy and safety of 1% and 2% rebamipide clear solution in dry eye disease: a multicenter randomized trial

BACKGROUND

To evaluate the efficacy of 1% and 2% rebamipide clear solution in the treatment of dry eye disease (DED).

METHODS

Two hundred twenty patients with DED were randomly assigned to one of three groups: the 1% rebamipide, 2% rebamipide, or placebo (eye drops containing the same ingredients, except for the active components). Each eye drop was instilled four times daily for 12 weeks. Changes in tear film break-up time (TBUT), corneal and conjunctival staining score, Schirmer 1 test, and the Ocular Surface Disease Index (OSDI) from baseline to 12-week visit between the study groups were compared for efficacy assessment.

RESULTS

The mean age of study patients was 43.8±14.2 years. The 1% and 2% rebamipide groups showed greater improvement in TBUT (1.99±1.87 and 2.02±2.21 s) at 12 weeks from baseline than the placebo group (1.25±2.93 s). The 2% rebamipide group showed greater improvement in the corneal staining score (- 3.15±2.00) at 12 weeks from baseline than the placebo group (- 2.85±1.80). The 1% and 2% rebamipide groups showed improvement in Schirmer 1 test (1.27±3.86 and 1.50±4.14 mm) at 12 weeks of treatment, but not the placebo group (0.55±2.99 mm). Both the rebamipide groups and the placebo group showed significantly improved OSDI after treatment for 12 weeks; however, there was no significant difference among the three groups.

CONCLUSIONS

1% and 2% rebamipide clear solutions are an effective therapeutic option for improving TBUT and tear volume, and stabilizing the corneal staining score in DED.

Dry eye in Parkinson's disease: a narrative review

In Parkinson's disease (PD) patients, a wide range of ocular and visual disorders are present. Tear film instability, inflammation and dysfunction of the ocular surface, and the presence of symptoms of visual disturbance characterize dry eye, a multifactorial disease of the ocular surface. Based on a literature search, we discuss the frequency, pathogenesis, and influence on the quality of life of patients with dry eye in Parkinson's disease. Furthermore, we review the available means of diagnosis and management of dry eye. An improvement in awareness and recognition of dry eye is needed to provide suitable, personalized therapeutic options for PD patients, aiming to improve their quality of life, independence, and safety.

Hyperosmolarity promotes macrophage pyroptosis by driving the glycolytic reprogramming of corneal epithelial cells in dry eye disease

Tear film hyperosmolarity plays a core role in the development of dry eye disease (DED) by mediating the disruption of ocular surface homeostasis and triggering inflammation in ocular surface epithelium. In this study, the mechanisms involving the hyperosmolar microenvironment, glycolysis mediating metabolic reprogramming, and pyroptosis were explored clinically, in vitro, and in vivo. Data from DED clinical samples indicated that the expression of glycolysis and pyroptosis-related genes, including PKM2 and GSDMD, was significantly upregulated and that the secretion of IL-1β significantly increased. In vitro, the indirect coculture of macrophages derived from THP-1 and human corneal epithelial cells (HCECs) was used to discuss the interaction among cells. The hyperosmolar environment was found to greatly induce HCECs' metabolic reprogramming, which may be the primary cause of the subsequent inflammation in macrophages upon the activation of the related gene and protein expression. 2-Deoxy-d-glucose (2-DG) could inhibit the glycolysis of HCECs and subsequently suppress the pyroptosis of macrophages. In vivo, 2-DG showed potential efficacy in relieving DED activity and could significantly reduce the overexpression of genes and proteins related to glycolysis and pyroptosis. In summary, our findings suggested that hyperosmolar-induced glycolytic reprogramming played an active role in promoting DED inflammation by mediating pyroptosis.

Meibomian gland dysfunction and blepharitis: A common and still unsolved ophthalmic problem

Blepharitis and meibomian gland dysfunction (MGD) are very common, usually underdiagnosed and underappreciated diseases. More than 50% of patients seeking ophthalmologic consultations have symptoms and signs indicating one or both entities. We summarize the key points of diagnosis and management of both diseases, comparing the work of Dry Eye Workshop II (2017) with the dry eye blepharitis syndrome unification theory. The impact of MGD/blepharitis on ocular surgery also is described. Although MGD and blepharitis seem to be uncurable, most of the time they can be successfully controlled. Different management options are available, but the key to success remains simple-routine eyelid hygiene and moisturizing with the use of preservative-free lubricants.

Usage of topical insulin for the treatment of diabetic keratopathy, including corneal epithelial defects

BACKGROUND

Diabetic keratopathy (DK) occurs in 46%-64% of patients with diabetes and requires serious attention. In patients with diabetes, the healing of corneal epithelial defects or ulcers takes longer than in patients without diabetes. Insulin is an effective factor in wound healing. The ability of systemic insulin to rapidly heal burn wounds has been reported for nearly a century, but only a few studies have been performed on the effects of topical insulin (TI) on the eye. Treatment with TI is effective in treating DK.

AIM

To review clinical and experimental animal studies providing evidence for the efficacy of TI to heal corneal wounds.

METHODS

National and international databases, including PubMed and Scopus, were searched using relevant keywords, and additional manual searches were conducted to assess the effectiveness of TI application on corneal wound healing. Journal articles published from January 1, 2000 to December 1, 2022 were examined. The relevancy of the identified citations was checked against predetermined eligibility standards, and relevant articles were extracted and reviewed.

RESULTS

A total of eight articles were found relevant to be discussed in this review, including four animal studies and four clinical studies. According to the studies conducted, TI is effective for corneal re-epithelialization in patients with diabetes based on corneal wound size and healing rate.

CONCLUSION

Available animal and clinical studies have shown that TI promotes corneal wound healing by several mechanisms. The use of TI was not associated with adverse effects in any of the published cases. Further studies are needed to enhance our knowledge and understanding of TI in the healing of DK.

High Prevalence of Symptomatic Dry Eye Disease Among University Students During the COVID-19 Pandemic in University of West Indies, Trinidad and Tobago

BACKGROUND

The Covid-19 pandemic lockdown obligated higher education students to attend online courses, leading to prolonged exposure to digital displays. Excessive time on digital devices could be a risk factor for ocular problems, including symptomatic dry eye. There are limited evidences to show the magnitude of symptomatic dry eye disease and its associated factors during COVID-19 pandemic. This study aimed to fill this gap, among university students in Trinidad and Tobago.

METHODS

An institutional-based cross-sectional study was conducted among undergraduate students attending the University of West Indies, Saint Augustine Campus from October 2020 to April 2021. The standardized ocular surface disease index questionnaire, descriptive statics and binary logistic regression were used to assess the prevalence and associated factors of dry eye diseases. Variables with a p-value of less than 0.05 were considered to be statistically significant.

RESULTS

Four hundred (96.3%) participants completed the questionnaire. Among all, 64.8% were female and 50.5% were east Indians. About 48% were using visual display units for average of 10-15 hours/day. The prevalence of symptomatic dry eye disease was 84.3% (95% CI = 80.8-87.5%) with OSDI score ≥13. Lack of education about dry eye 2.69 (95% CI: 1.41-5.13), use of the reading mode of computer 3.92 (95% CI: 1.57-9.80), refractive error 3.20 (95% CI: 1.66-6.20), previous systemic medications 2.80 (95% CI: 1.15-6.81), and average hours of visual display unit use/day (p<0.001) were significantly associated with symptomatic dry eye disease.

CONCLUSION

Symptomatic dry eye disease was a prominent problem among students at the University of West Indies. Average of >4 hours of visual display unit use/day, refractive error, positive history of systemic medication, lack of education about dry eye, and using computers in reading mode were associated factors.

Anthocyanin oligomer (grape skin extract) administration improves dry eye disease: A randomised, double-blind, placebo-controlled study

BACKGROUND

Dry eye disease is a chronic, progressive ocular disease characterised by ocular discomfort and is one of the most common ophthalmological disorders that affects people's lives.

METHODS

This study investigated the clinical efficacy of anthocyanin oligomers (grape skin extract) for the treatment of dry eye. One hundred and eight patients with dry eye were randomly divided into placebo and treatment groups, each with 54 cases. The placebo group received maltodextrin (800 mg/day) and the treatment group received anthocyanin oligomers (800 mg/day). Clinical efficacy, clinical indices, and occurrence of adverse reactions were compared between the two groups.

RESULTS

Anthocyanin oligomers were safe and effective in mild-to-moderate dry eye disease, improving the tear break-up time, intraocular pressure, ocular surface disease, and patient symptomatology.

CONCLUSIONS

The use of oral anthocyanin oligomers in the treatment of dry eye patients can enhance the therapeutic effect and improve the quality of life of patients while ensuring the safety of treatment, making this therapeutic option suitable for wider application.

A Randomised Phase I Study to Assess the Safety, Tolerability and Pharmacokinetics of Palovarotene Ophthalmic Solution

BACKGROUND AND OBJECTIVE

Palovarotene, a selective retinoic acid receptor γ agonist, is under investigation for the treatment of dry eye disease. This study aimed to determine the ocular and systemic safety, tolerability and pharmacokinetics of palovarotene ophthalmic solution (PVO-OS) in healthy adults.

METHODS

This was a randomised, vehicle-controlled phase I study (NCT04762355; retrospectively registered). Participants received either PVO-OS (at 0.025, 0.05 or 0.10 mg/mL) or a vehicle (placebo-to-match PVO-OS) once-daily or twice-daily for seven consecutive days. Safety was assessed by ocular and systemic assessments. Blood samples for pharmacokinetic assessments were collected before and after dose administration.

RESULTS

Thirty-six participants were randomised to PVO-OS and 12 to the vehicle. Overall, 89 treatment-emergent ocular adverse events (TEOAEs) were reported by 22 participants (61.1%) receiving PVO-OS and ten TEOAEs were reported by five participants (41.7%) receiving the vehicle. Erythema, irritation and skin dryness of the eyelid were the most common TEOAEs in participants receiving PVO-OS. The incidence of TEOAEs and eyelid-related findings in the PVO-OS groups increased with ascending dose and frequency compared with participants treated with the vehicle. All TEOAEs were mild (96.6%) or moderate (3.4%) and resolved without sequelae. Plasma palovarotene concentrations were generally measurable for up to 3-4 h for 0.025 mg/mL and 0.05 mg/mL and up to 12 h for 0.10 mg/mL dose regimens, independent of the frequency of administration.

CONCLUSIONS

PVO-OS was generally well tolerated at doses up to and including 0.10 mg/mL twice daily. Similar pharmacokinetic profiles were observed for the once-daily and twice-daily regimens following multiple ascending doses of PVO-OS.

Narrative Review Concerning the Clinical Spectrum of Ophthalmological Impairments in Parkinson's Disease

Ophthalmic non-motor impairments are common in Parkinson's disease patients, from the onset of the neurodegenerative disease and even prior to the development of motor symptoms. This is a very crucial component of the potential for early detection of this disease, even in its earliest stages. Since the ophthalmological disease is extensive and impacts all extraocular and intraocular components of the optical analyzer, a competent assessment of it would be beneficial for the patients. Because the retina is an extension of the nervous system and has the same embryonic genesis as the central nervous system, it is helpful to investigate the retinal changes in Parkinson's disease in order to hypothesize insights that may also be applicable to the brain. As a consequence, the detection of these symptoms and signs may improve the medical evaluation of PD and predict the illness' prognosis. Another valuable aspect of this pathology is the fact that the ophthalmological damage contributes significantly to the decrease in the quality of life of patients with Parkinson's disease. We provide an overview of the most significant ophthalmologic impairments associated with Parkinson's disease. These results certainly constitute a large number of the prevalent visual impairments experienced by PD patients.

Validation of a Modified National Eye Institute Grading Scale for Corneal Fluorescein Staining

Purpose

Validation of the novel Lexitas modified NEI scale for use in assessment of corneal fluorescein staining.

Patients and Methods

A series of 18 illustrations and 14 clinical photographs depicting varying severity levels of corneal fluorescein staining were assessed by 3 independent examiners. Regions of the cornea were graded for staining severity based on 3 different grading scales: the original NEI staining scale (density-based scoring; 0-3 scale), a structured version of the NEI scale (dot-count scoring; 0-3 scale), and the Lexitas modified NEI staining scale (0-4 scale with half-point increments). Kappa statistics (simple and weighted) were computed to determine intra-examiner image grading repeatability for each examiner over 2 separate assessments. Inter-examiner assessment reliability utilized the scores from the first read of each examiner, and pairs of examiners to compute kappa statistics.

Results

Data was analyzed from the scores provided by the examiners from each gradable corneal region on 32 images (18 illustrations and 14 photographs) for a total of 154 corneal regions across the 3 grading scales for each validation run. The mean intra-examiner simple/weighted kappa values using the NEI density, NEI dot count, and the Lexitas modified NEI staining scales were 0.67/0.72, 0.91/0.94, 0.80/0.92 for the graded illustrations, and 0.83/0.88, 0.76/0.85, 0.77/0.88 for the graded photographs, respectively. The mean inter-examiner simple/weighted kappa values using the NEI density, NEI dot count, and the Lexitas modified NEI staining scales were 0.59/0.65, 0.86/0.90, and 0.78/0.91 for the graded illustrations, and 0.80/0.88, 0.84/0.89, 0.69/0.88 for the graded photographs, respectively.

Conclusion

The expanded scale of the Lexitas modified NEI staining scale demonstrated a high degree of reliability and repeatability of grading assessments within and across individual examiners, comparing favorably with the original NEI staining scale. A future investigation into the in-office utility of the Lexitas modified NEI staining scale is warranted.

Role of stem cells in regenerative treatment of dry eye disease caused by lacrimal gland dysfunction

An ageing population and increased screen use in younger people have contributed to a rise in incidence of dry eye disease (DED). Quality of life can be significantly affected by DED, with patients experiencing eye dryness, burning, pain and sensitivity to light. If left untreated, DED may progress to cause lasting damage to the delicate cell layers of the ocular surface. The aqueous-deficient form of DED is characterized by decreased tear volume. This can occur through underlying disease or damage to the lacrimal gland (LG), which results in increased inflammation at the ocular surface and decreased tear secretion. Regenerative therapy for treatment of aqueous-deficient DED would ideally restore LG function without causing adverse side effects and be feasible in terms of cost, production and practical application in the clinic. In this review, we evaluate research directed at the development of clinical procedures for regeneration of the LG using various stem cell types and their products. We also discuss work identifying potential therapeutic targets that may alter pathways to effect healing and ameliorate development of DED. Finally, we discuss shortcomings and recommend future avenues for research. These include determination of the best tissue of origin for mesenchymal cells and transference of knowledge gleaned from animal studies to clinical investigations.

Difficulties in Performing Daily Activities in Patients with Dry Eye before and after Treatment

Dry eye disease (DED) represents an important public health problem causing visual discomfort which affects the quality of life. This paper investigates the current comprehension of DED on life quality and vision.

METHODS

This research consists of a cross-sectional study of 121 patients, with a mean age of 70 ± 9 years, diagnosed with DED. All patients were treated in the University Clinic for Ophthalmology in "St. Spiridon" Emergency Hospital, Iasi. For all patients, we evaluated visual acuity on the Snellen chart, tear breakup time (TBUT), Schirmer I test scores, and contrast sensitivity. For this study, we used the Visual Functioning Questionnaire-25 (VFQ-25) version 2000, modified and adapted for this research (19 items).

RESULTS

Prior to treatment, patients had very high difficulty reading a text in a newspaper or on TV, reading prices on products in shops, or recognizing people they already met. Performing manual work or favorite activities was also very difficult. Post-treatment visual challenges improved in the majority of cases, regardless of the treatment method used.

CONCLUSIONS

We found that symptomatic dry eye disease was associated with reduced ability in performing several important vision-related daily tasks and has a significant impact on life quality and visual performance.

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

Introduction

Early initiation of anti-inflammatory therapies is recommended for dry eye disease (DED) to break the vicious cycle of pathophysiology. However, there is limited guidance on how to implement topical ciclosporin (CsA) and corticosteroid treatment into clinical practice. This expert-led consensus provides practical guidance on the management of DED, including when and how to use topical CsA.

Methods

A steering committee (SC) of seven European DED experts developed a questionnaire to gain information on the unmet needs and management of DED in clinical practice. Consensus statements on four key areas (disease severity and progression; patient management; efficacy, safety and tolerability of CsA; and patient education) were generated based on the responses. The SC and an expanded expert panel of 22 members used a nine-point scale (1  =  strongly disagree; 9  =  strongly agree) to rate statements; a consensus was reached if ≥75% of experts scored a statement ≥7.

Results

A stepwise approach to DED management is required in patients presenting with moderate corneal staining. Early topical CsA initiation, alone or with corticosteroids, should be considered in patients with clinical risk factors for severe DED. Patient education is required before and during treatment to manage expectations regarding efficacy and tolerability in order to optimise adherence. Follow-up visits are required, ideally at Month 1 and every 3 months thereafter. Topical CsA may be continued indefinitely, especially when surgery is required.

Conclusion

This consensus fills some of the knowledge gaps in previous recommendations regarding the use of topical corticosteroids and CsA in patients with DED.

Effectiveness of Topical Cyclosporin A 0.1%, Diquafosol Tetrasodium 3%, and Their Combination, in Dry Eye Disease

Purpose: To compare the effectiveness of the topical use of cyclosporin A (CsA) 0.1%, diquafosol (DQS) tetrasodium 3% ophthalmic solution, and their combination in treating dry eye disease in a general health care setting. Methods: This prospective, nonrandomized, observational study analyzed 279 patients. Patients instilled topical CsA 0.1% (Ikervis^®; Santen Pharmaceutical Co., Ltd., Japan) once daily and/or DQS tetrasodium 3% (Diquas-S^®; Santen) six times a day for 12 weeks. Objective signs [tear break-up time (TBUT), National Eye Institute (NEI) corneal and conjunctival staining scores] and symptoms [Symptom Assessment in Dry Eye (SANDE) and Dry Eye-related Quality-of-Life Score (DEQS) questionnaires] were evaluated at baseline, week 4, and week 12. Results: Patients (n = 279) were mainly female (85.0%) with a mean (SD) age of 50.1 (14.8) years, and received CsA (n = 93), DQS (n = 99), or CsA/DQS (n = 87). Both monotherapies and CsA/DQS combination therapy significantly improved TBUT, NEI corneal and conjunctival staining scores, and SANDE and DEQS scores from baseline to week 12 (all P < 0.0001). The mean change in TBUT between baseline and week 12 was significantly higher in CsA/DQS combination therapy (2.13 ± 2.41 s) than in CsA monotherapy (1.07 ± 1.71 s; P = 0.0011). Conclusions: Monotherapy with CsA or DQS and CsA/DQS combination therapy all significantly improved the objective signs and symptoms of dry eyes during 12 weeks of treatment. CsA/DQS combination therapy provides an additional benefit in terms of TBUT compared with CsA alone; however, a randomized controlled trial still needs to be performed to confirm this result.

The effect of sodium hyaluronate on tear film stability in patients with dry eye syndrome after cataract surgery

BACKGROUND

This study aimed to observe the changes in the ocular surface after phacoemulsification in patients with age-related cataracts with respect to the addition of varying concentrations of hyaluronate.

METHODS

Patients with dry eye syndrome were treated with 0.3% and 0.1% sodium hyaluronate eye drops to evaluate the clinical improvement in each treatment group. A total of 73 patients (91 eyes) with age-related cataracts suffering from dry eye syndrome after phacoemulsification were divided into treatment group A (30 eyes), undergoing conventional therapy and treatment with 0.3% sodium hyaluronate; treatment group B (31 eyes), undergoing conventional therapy and treatment with 0.1% sodium hyaluronate; and the control group (group C; 30 eyes), undergoing conventional therapy only. Two groups were given different concentrations of sodium hyaluronate eye drops four times a day (should be completed between 8 AM and 8 PM), one drop at a time.

RESULTS

Seven days, 2 weeks, 1 month, and 2 months postoperatively, there were significant differences in the Schirmer I test (SIt), first noninvasive tear film break-up time (NIBUTf), average noninvasive tear film break-up time (NIBUTav), tear meniscus height (TMH), and irregularity (when the refractive force of different parts of different meridians on the same meridian is different. The main manifestation is that the two meridians on the anterior surface of the cornea do not show a 90-degree vertical distribution, which cannot be corrected by conventional astigmatism lenses) between the three groups (p < 0.05). When compared with group C, there were significant differences in the SIt, NIBUTf, NIBUTav, TMH, and irregularity of group A and group B (p < 0.05). When compared with group B, there were significant improvements in the SIt, NIBUTf, NIBUTav, and TMH in group A (p < 0.05).

CONCLUSIONS

In the early stage after phacoemulsification, the stability of the tear film is reduced. Adding sodium hyaluronate eye drops can restore tear film structure and improve corneal surface regularity, and a 0.3% solution of sodium hyaluronate eye drops is more effective than a 0.1% solution.

Therapeutic Potential of d-MAPPS™ for Ocular Inflammatory Diseases and Regeneration of Injured Corneal and Retinal Tissue

The invasion of microbial pathogens and/or sterile inflammation caused by physical/chemical injuries, increased ocular pressure, oxidative stress, and ischemia could lead to the generation of detrimental immune responses in the eyes, which result in excessive tissue injury and vision loss. The bioavailability of eye drops that are enriched with immunoregulatory and trophic factors which may concurrently suppress intraocular inflammation and promote tissue repair and regeneration is generally low. We recently developed “derived- Multiple Allogeneic Proteins Paracrine Signaling regenerative biologics platform technology d-MAPPS™”, a bioengineered biological product which is enriched with immunomodulatory and trophic factors that can efficiently suppress detrimental immune responses in the eye and promote the repair and regeneration of injured corneal and retinal tissues. The results obtained in preclinical and clinical studies showed that d-MAPPS™ increased the viability of injured corneal cells, inhibited the production of inflammatory cytokines in immune cells, alleviated inflammation, and restored vision loss in patients suffering from meibomian gland dysfunction and dry eye disease. Herewith, we emphasized molecular mechanisms responsible for the therapeutic efficacy of d-MAPPS™ and we presented the main beneficial effects of d-MAPPS™ in clinical settings, indicating that the topical administration of d-MAPPS™ could be considered a new therapeutic approach for the treatment of ocular inflammatory diseases and for the repair and regeneration of injured corneal and retinal tissues.

Effect of multivitamin drug on intractable dry eye symptoms

Dry eye is a disorder of tear film and ocular surface characterized by ocular discomforts. It is associated with multiple causes and sometimes intractable. We investigated the effect of oral multivitamin supplementation (MVG) on dry eyes. Tear break-up time (TBUT), fluorescein ocular surface staining score, and tear secretion Schirmer test were measured in dry eye patients refractory to conventional topical treatment. The ocular surface disease index (OSDI), visual analog pain score (VAS), and modified standardized patient evaluation of eye dryness questionnaire were analyzed. In total, 42 eyes of 42 patients were included. TBUT increased at 1 and 3 months compared to baseline (p < 0.05). OSDI decreased at 1 and 3 months compared to baseline (p < 0.05). VAS score, impact on life, and frequency of total symptoms decreased at 3 months compared to baseline (p < 0.05). Oral administration of MVG, a vitamin complex formulation, was effective in stabilizing tear stability and alleviating symptoms in patients with intractable dry eye. Thus, it may be a viable treatment option for intractable dry eye.

Comparison of Sodium-Glucose Cotransporter 2 Inhibitors vs Glucagonlike Peptide-1 Receptor Agonists and Incidence of Dry Eye Disease in Patients With Type 2 Diabetes in Taiwan

IMPORTANCE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been found to improve low-grade systemic and tissue inflammation; however, the association between SGLT2 inhibitor use and the incidence of dry eye disease (DED) has not been explored.

OBJECTIVE

To investigate the association between SGLT2 inhibitor use and dry eye disease in patients with type 2 diabetes (T2D).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis of the largest multi-institutional electronic medical records database in Taiwan was conducted to identify patients with T2D newly receiving SGLT2 inhibitors or glucagonlike peptide-1 receptor agonists (GLP-1 RAs) from 2016 to 2018. Data analysis was performed from March 1 to May 31, 2022. Propensity scores with inverse probability of treatment weighting were generated to enable homogeneous comparisons between the 2 groups.

EXPOSURES

Treatment with SGLT2 inhibitors or GLP-1 RAs.

MAIN OUTCOMES AND MEASURES

Incident dry eye disease, which was defined by clinical diagnoses, plus the related drug prescription. Cox proportional hazards regression models were used to estimate hazard ratios with 95% CIs for the risk of DED.

RESULTS

A total of 10 038 and 1077 T2D patients newly receiving SGLT2 inhibitors (mean [SD] age, 59.5 [12.1] years; 5689 [56.7%] men) or GLP-1 RAs (mean [SD] age, 58.5 [41.2] years; 587 [54.5%] men), respectively, were included in the analysis. The incidence of DED was lower in patients newly receiving SGLT2 inhibitors (9.0 events per 1000 person-years) compared with those receiving GLP-1 RAs (11.5 events per 1000 person-years), yielding a hazard ratio of 0.78 (95% CI, 0.68-0.89). Subgroup analyses indicated that the lowered DED risks associated with SGLT2 inhibitors in patients with T2D were similar across different age, sex, blood glucose level, and kidney function groups. Results from the sensitivity analyses (including the propensity score-matching approach, on-treatment analyses, and different follow-up periods of 1, 2, and 3 years) were similar to the main analyses.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that patients with T2D newly receiving SGLT2 inhibitors may have a lower risk for DED compared with those receiving GLP-1 RAs. Prospective studies are needed to analyze these results.

Current trends in pharmaceutical treatment of Dry Eye Disease: A review

Dry eye disease (DED), keratoconjunctivitis sicca or dysfunctional tear syndrome, is the most prevalent ophthalmic disease which affects a substantial segment of people worldwide with increasing frequency. It is considered a multifactorial disease of the ocular surface and tear film, characterized by a variation of signs and symptoms. The symptoms range from mild to severe itching, burning, irritation, eye fatigue, and ocular inflammation that may lead to potential damage to the cornea, conjunctiva and even vision loss. Correspondingly, depending on the different manifestations and pathophysiology, the treatment must be tailored specifically to each patient by targeting the specific mechanisms implicated in their disease. Currently, there are several medical products and techniques available or under investigation for the treatment of DED. The present article focused on the pathophysiology of DED, the new diagnostic approach and the recently developed drug delivery systems or devices reducing the progress of the disease and treating the causes.

Undetected ophthalmological disorders in Parkinson's disease

Background

Ophthalmological disorders are common and frequently disabling for people with Parkinson’s disease (PD). However, details on the prevalence, severity and impact of ophthalmological disorders thus far lacking. We aimed to identify PD patients with undetected ophthalmological disorders in a large cross-sectional, observational study.

Methods

We previously delivered a screening questionnaire to detect ophthalmological symptoms (Visual impairment in PD questionnaire; VIPD-Q) to 848 patients. Here, we report on a subgroup of 102 patients who received complete ophthalmological assessment aimed at identifying clinically relevant ophthalmological diseases, which were classified as either vison-threatening or not. Impact on daily life functioning was measured using the visual functioning-25 questionnaire (VFQ-25) and fall frequency.

Results

Almost all patients (92%) had one or more clinically relevant ophthalmological disorders. Of those, 77% had a potentially vision-threatening disease, while 34% had a potentially treatable ophthalmological disease which impacted on quality of life. The most prevalent ophthalmological disorders were dry eyes (86%), ocular misalignment (50%) and convergence insufficiency (41%). We found a weak but significant association between clinically relevant ophthalmological diseases and both fall frequency (R² = 0.15, p = 0.037) and VFQ-25 score (R² = 0.15, p = 0.02). The VIPD-Q could not correctly identify patients with relevant ophthalmological disorders.

Conclusions

Surprisingly, in our study sample, many participants manifested previously undetected ophthalmological diseases, most of which threatened vision, impacted on daily life functioning and were amenable to treatment. Screening for these ophthalmological disorders using a questionnaire asking about symptoms seems insufficient. Instead, episodic ophthalmological assessments should be considered for PD patients, aiming to identify vision-threatening yet treatable diseases.

Trial registration

Dutch Trial Registration, NL7421.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11014-0.

Biophysical properties of tear film lipid layer I. Surface tension and surface rheology

Tear film lipid layer (TFLL) is the outmost layer of the tear film. It plays a crucial role in stabilizing the tear film by reducing surface tension and retarding evaporation of the aqueous layer. Dysfunction of the TFLL leads to dysfunctional tear syndrome, with dry eye disease (DED) being the most prevalent eye disease, affecting 10%-30% of the world population. To date, except for treatments alleviating dry eye symptoms, effective therapeutic interventions in treating DED are still lacking. Therefore, there is an urgent need to understand the biophysical properties of the TFLL with the long-term goal to develop translational solutions in effectively managing DED. Here, we studied the composition-function correlations of an artificial TFLL, under physiologically relevant conditions, using a novel experimental methodology called constrained drop surfactometry. This artificial TFLL was composed of 40% behenyl oleate and 40% cholesteryl oleate, representing the most abundant wax ester and cholesteryl ester in the natural TFLL, respectively, and 15% phosphatidylcholine and 5% palmitic-acid-9-hydroxy-stearic-acid (PAHSA), which represent the two predominant polar lipid classes in the natural TFLL. Our study suggests that the major biophysical function of phospholipids in the TFLL is to reduce the surface tension, whereas the primary function of PAHSA is to optimize the rheological properties of the TFLL. These findings have novel implications in better understanding the physiological and biophysical functions of the TFLL and may offer new translational insight to the treatment of DED.

The Efficacy of Kohl (Surma) and Erythromycin in Treatment of Blepharitis: An Open-Label Clinical Trial

Introduction

Blepharitis is a common and chronic form of eyelid inflammation. Blepharitis treatment aims to decrease symptoms through antibacterial effects. One of the most common treatments of eyelid diseases in traditional medicine is using kohl. This clinical trial aimed to investigate its efficacy as a complementary treatment in staphylococcal blepharitis through an open-label clinical trial.

Materials and Methods

Thirty patients were randomized to receive kohl in one eye contralateral and erythromycin ointment in another eye for 90 days. At baseline and after 90 days of treatment, symptoms, clinical signs, and side effects of treatments were recorded. Statistical analysis was carried out using SPSS software, version 19.

Results

Despite randomization, there was a significant difference between the intervention and control eyes in the baseline mean clinical score (intervention eye: 9.86 (2.95) and control eye: 4.30 (2.81), P < 0.001). The degree of reduction of related signs and symptoms in the eyes treated with kohl was significantly higher than that in the control group: (5.2 vs. 2.20, P < 0.001) for symptoms and (7.40 vs. 2.46, P < 0.001) for clinical signs. Cohen's d statistic for mean difference of sign and symptom was 2.4 and 1.75, respectively, indicating a very strong effect.

Conclusion

The present study results demonstrated a significant improvement in blepharitis-related signs and symptoms. The degree of improvement in the eyes treated with kohl was much higher than that in the control eyes.

The use of androgen deprivation therapy for prostate cancer and its effect on the subsequent dry eye disease: a population-based cohort study

This study aimed to investigate the influence of androgen deprivation therapy (ADT) for the development of dry eye disease (DED) in subjects with prostate cancer via the use of national health insurance research database (NHIRD) of Taiwan. A retrospective cohort study was conducted and patients were selected as prostate cancer with ADT according to diagnostic and procedure codes. Each participant in that group was then matched to one patient with prostate cancer but without ADT and two subject s without prostate cancer and ADT. And a total of 1791, 1791 and 3582 participants were enrolled in each group. The primary outcome was set as the DED development according to the diagnostic codes. Cox proportional hazard regression was applied to calculate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) of ADT and other parameters for DED development. There were 228, 126 and 95 new events of DED developed in the control group, the prostate cancer without ADT group and the prostate cancer with ADT group. The rate of DED in the prostate cancer with ADT group (aHR: 0.980, 95% CI: 0.771-1.246, P= 0.8696) and Prostate cancer without ADT group (aHR: 1.064, 95% CI: 0.855-1.325, P= 0.5766) were not significantly different compared to the control group. In addition, the patients aged 70-79 years old demonstrated a significantly higher incidence of developing DED compared to those aged 50-59 years old (aHR: 1.885, 95% CI: 1.188-2.989, P= 0.0071). In conclusion, the use of ADT did not alter the incidence of subsequent DED.

Spatial transcriptomics of the lacrimal gland features macrophage activity and epithelium metabolism as key alterations during chronic inflammation

The lacrimal gland (LG) is an exocrine gland that produces the watery part of the tear film that lubricates the ocular surface. Chronic inflammation, such as Sjögren's syndrome (SS), is one of the leading causes of aqueous-deficiency dry eye (ADDE) disease worldwide. In this study we analyzed the chronic inflammation in the LGs of the NOD.B10Sn-H2b/J (NOD.H-2b) mice, a mouse model of SS, utilizing bulk RNAseq and Visium spatial gene expression. With Seurat we performed unsupervised clustering and analyzed the spatial cell distribution and gene expression changes in all cell clusters within the LG sections. Moreover, for the first time, we analyzed and validated specific pathways defined by bulk RNAseq using Visium technology to determine activation of these pathways within the LG sections. This analysis suggests that altered metabolism and the hallmarks of inflammatory responses from both epithelial and immune cells drive inflammation. The most significant pathway enriched in upregulated DEGs was the "TYROBP Causal Network", that has not been described previously in SS. We also noted a significant decrease in lipid metabolism in the LG of the NOD.H-2b mice. Our data suggests that modulation of these pathways can provide a therapeutic strategy to treat ADDE.

Therapeutic Potential of „Derived-Multiple Allogeneic Proteins Paracrine Signaling-D-Mapps” in the Treatment of Dry Eye Disease

Dry eye disease (DED) is a chronic inflammatory disease of the lacrimal system and ocular surface. Considering the important role of inflammation in DED development, the main treatment strategy has shifted from hydration and lubrication of dry ocular surface to the immunomodulation and immunoregulationapproach that should address the main pathologic processes responsible for disease progression. Due to their capacity for production of immunosuppressive factors, mesenchymal stem cells (MSCs) and their secretome have been considered as potentially new agents in DED therapy. We recently developed an immunomodulatory ophthalmic solution “derived- Multiple Allogeneic Proteins Paracrine Signaling (d-MAPPS)” which activity is relied on immunosuppressive capacity of MSC-derived secretome. d-MAPPS contains MSC-derived exosomes, growth factors and immunosuppressive cytokines that are able to efficiently suppress generation of inflammatory phenotype in T cells and macrophages. Herewith, we demonstrated that d-MAPPS protected human corneal epithelial cells from chemical injury and efficiently alleviated ocular discomfort and pain in 131 DED patients during the 12-month follow-up, indicating d-MAPPS eye drops as potentially new remedy for the treatment of DED patients.

Treatment of Severe Ptosis by Conjoint Fascial Sheath Suspension

Objective

To explore the role of conjoint fascial sheath (CFS) suspension in the treatment of severe ptosis.

Methods

A total of 110 patients with severe ptosis who were admitted to our hospital from May 2018 to December 2020 were included. Fifty-seven patients treated with frontalis suspension were assigned into group A, and the remaining 53 patients treated with CFS suspension were assigned into group B. The curative effect, ocular surface alterations, complications, and satisfaction in the two groups were compared.

Results

Patients in group B suffered from severe upper eyelid retraction and lid lag than those in group A, as well as more limited range of motion (ROM) (P < 0.05). The curative effect and patient satisfaction in group B were higher than those in group A (P < 0.05). Postsurgical complications in group B were fewer than those in group A (P < 0.05).

Conclusion

CFS suspension is effective in the treatment of severe ptosis.

Corneal protective effects of novel tear substitutes containing sodium hyaluronate and dodecahydrosqualene, squalane, in a porcine dry eye model

To develop a novel tear substitute (TS) containing sodium hyaluronate (SH) and dodecahydrosqualene (DHS, squalane), we improved the prescription of a previously developed TS containing saline, 0.5% SH and 1% castor oil (CO), which had corneal protective effects against 60-min desiccation in a porcine dry eye model and viscosity of 106.8 mPa·S. Fresh porcine eyes were treated with a TS containing saline, 0.1%, 0.25%, 0.3% or 0.5% SH, and 1% CO or 1%, 2.5% or 5% DHS, and TS-treated eyes were desiccated for up to 180 min. The corneal damage was evaluated by the staining score of methylene blue (MB), absorbance of MB extracted from the cornea, the staining density of lissamine green (LG) and histopathology. The viscosities of the examined TS were also measured. A saline/0.5% SH/1% DHS solution had corneal protective effects for 90 min under desiccation and a viscosity of 110.0 mPa·s. A TS with saline, 0.1%, 0.25% or 0.3% SH and 1% or 2.5% DHS did not have better protective effects than a saline/0.5% SH/1% DHS solution, although a saline/0.3% SH/5% DHS solution exhibited greater corneal protection against 180-min desiccation on MB and LG staining and histopathological examination, and its viscosity was 34.5 mPa·s, which was similar to the 29.5 mPa·s of 0.3% SH. The saline/0.3% SH/5% DHS solution is available as a novel 3-hr long-lasting TS containing mucinomimetic and liquid oil components to treat and relieve dry eye symptoms in animals and humans.

Transregional autologous serum eye drop provision by a large German Red Cross Blood Donation Service

BACKGROUND

The Blood Donation Service West serves North Rhine-Westphalia (NRW), Rhineland-Palatinate (RP), and Saarland, an area of 56,500 km². In addition to routine red blood cell concentrates, plasma, and platelets, special products are provided. Since 2014, this has included autologous serum eye drops (ASED) for topical use in patients suffering from different illnesses accompanied by dry eye disease.

METHODS

A volume of 250-525 mL of patient blood was collected into an anticoagulant-free blood bag. Laboratory testing included Hepatitis B/C-, HIV 1/2-, and Lues-serology. Coagulation and centrifugation were followed by leukoreduction. Single-use vials were obtained by filling mini-bag systems using a sterile tube welder. Storage at ≤-20 °C enabled a shelf-life of up to 6 months and 30 days at 4 °C after thawing for shipment.

RESULTS

Contracts were closed with 15 ophthalmology clinics and medical practices in NRW and RP to supply patients with ASED. The patient pool increased from 19 in 2014 to 46 in 2020, with an average age of 43-55 years. Overall, blood collections almost tripled from 31 to 100 per year, increasing the stock of deliverable single-use vials from 3328 to 13,358. Delivery in a liquid state allowed engagement of 44 pharmacies located in the patient neighborhoods for continuous supply.

CONCLUSION

Manufacturing in a closed bag system allowed integration into blood bank operations. However, cost-coverage by health insurance remained a case-by-case decision. Allogeneic application as 'just-another-blood-product' could be an aspiration. Yet, conclusive data from large clinical trials are needed for licensed provision in Germany.

Assessment of the correlation of the tear breakup time with quality of vision and dry eye symptoms after SMILE surgery

Purpose

It is well reported that dry eye symptoms can increase after many refractive surgery procedures. This study aims to provide a clinical understanding of the correlation of fluorescein tear film breakup time (FTBUT) with quality of vision (QoV) and dry eye symptoms following small incision lenticule extraction surgery (SMILE).

Methods

Patients electing to have SMILE surgery were subdivided into 2 groups: Group 1 included short preoperative FTBUTs of 3 to 6 seconds (s); Group 2 included long FTBUTs of ≥ 8 s. Uncorrected distance visual acuity, corrected distance visual acuity, manifest refraction, FTBUT, QoV and Ocular Surface Disease Index (OSDI) questionnaires were recorded 1 and 6 months postoperatively.

Results

Thirty-nine subjects were included in each group. There was no significant difference in visual outcomes between the 2 groups at both the 1- and 6-month postoperative assessments. FTBUT remained significantly lower in group 1. Oxford staining was initially higher for group 1 at 1 month (P = 0.007), but there was no significant difference at 6 months (P = 0.180). There was no significant difference in QoV or OSDI scores between the 2 groups at both postoperative visits.

Conclusions

Low preoperative FTBUT (3–6 s) does not appear to negatively affect postoperative visual outcomes or results in a greater likelihood of dry eye symptoms and poor ocular surface compared to eyes with a longer preoperative FTBUT. These results suggest that a low preoperative FTBUT does not necessarily increase the likelihood of poor visual acuity, dry eyes symptoms, or poor ocular surface outcomes following SMILE surgery.

Management of Visual Dysfunction in Patients with Parkinson's Disease

Parkinson’s disease (PD) is a movement disorder with many symptoms responsive to treatment with dopamine agonists, anti-cholinergics and the dopamine precursor, levodopa. The cardinal features of PD include tremor, rigidity, bradykinesia, and postural instability. There also are non-motor features that include sleep disorders, cognitive and affective dysfunction, hyposmia, pain and dysautonomia (constipation, bloating, orthostasis, urinary symptoms, sexual dysfunction, dysphagia). Among these non-motor features are signs and symptoms of visual system impairment that range from subtle examination findings to those causing severe disability. In this review we describe common PD-related abnormalities in the visual system, how they present, and potential treatments.

Quantitative analysis of morphological and functional features in Meibography for Meibomian Gland Dysfunction: Diagnosis and Grading

BACKGROUND

To explore the performance of quantitative morphological and functional analysis in meibography images by an automatic meibomian glands (MGs) analyser in diagnosis and grading Meibomian Gland Dysfunction (MGD).

METHODS

A cross-sectional study collected 256 subjects with symptoms related to dry eye and 56 healthy volunteers who underwent complete ocular surface examination was conducted between January 1, 2019, and December 31, 2020. The 256 symptomatic subjects were classified into MGD group (n = 195) and symptomatic non-MGD group (n = 61). An automatic MGs analyser was used to obtained multi-parametric measurements in meibography images including the MGs area ratio (GA), MGs diameter deformation index (DI), MGs tortuosity index (TI), and MGs signal index (SI). Adjusted odds ratios (ORs) of the multi-parametric measurements of MGs for MGD, and the area under the receiver operating characteristic (AUC-ROC) curves of multi-parametric measurements for MGD diagnosing and grading were conducted.

FINDINGS

When consider age, sex, ocular surface condition together, the estimated ORs for DI was 1.62 (95% CI, 1.29-2.56), low-level SI was 24.34 (95% CI, 2.73-217.3), TI was 0.76(95% CI, 0.54-0.90), and GA was 0.86 (95% CI, 0.74-0.92) for MGD. The combination of DI-TI-GA-SI showed an AUC = 0.82 (P < 0.001) for discriminating MGD from symptomatic subjects. The DI had a higher AUC in identifying early-stage MGD (grade 1-2), while TI and GA had higher AUCs in moderate and advanced stages (grade 3-5). Merging DI-TI-GA showed the highest AUCs in distinguish MGD severities.

INTERPRETATION

The MGs area ratio, diameter deformation, tortuosity and signal intensity could be considered promising biomarkers for MGD diagnosis and objective grading.

FUNDING

This work was supported by the Key-Area Research and Development Program of Guangdong Province (No. 2019B010152001), the National Natural Science Foundation of China under Grant (81901788) and Guangzhou Science and Technology Program (202002030412).

The Relationship Between Dry Eye Disease and Digital Screen Use

Dry eye disease is characterized by tear film instability that can result in ocular surface damage. Patients with dry eye disease may experience ocular pain/discomfort and visual disturbances that may negatively impact quality of life. Increased use of digital screens for work, communication, and entertainment, especially during times of pandemic, may contribute to dry eye. Extensive cross-sectional studies have shown that digital screen use duration is associated with an increased risk of severe symptoms and clinical diagnosis of dry eye disease in adults. Smartphone use duration has also been found to be greater in school-age children with dry eye disease than in those without dry eye disease. A commonly accepted hypothesis for the relationship between digital screen use and dry eye disease is that digital screen use changes blinking dynamics, leading to ocular dryness. This review describes evidence that digital screen use is associated with dry eye disease, that digital device use alters blinking dynamics, and that dry eye affects mental health and work productivity in digital screen users. Helpful prevention and management strategies for dry eye disease exist for those who use digital screens.

Recent Developments About the Pathogenesis of Dry Eye Disease: Based on Immune Inflammatory Mechanisms

Dry eye disease is a common and frequently occurring ophthalmology with complex and diverse causes, and its incidence is on the upward trend. The pathogenesis of DED is still completely clear. However, the immune response based on inflammation has been recognized as the core basis of this disease. In this review, we will systematically review the previous research on the treatment of DED in immune inflammation, analyze the latest views and research hotspots, and provide reference for the prevention and treatment of DED.

Flavonoid and cannabinoid impact on the ocular surface

PURPOSE OF REVIEW

To evaluate the impact of flavonoids and cannabinoids as anti-inflammatory and antiallergic treatments on the anterior surface of the eye.

RECENT FINDINGS

Allergic conjunctivitis and dry eye syndrome are common ocular surface diseases that have been treated with traditional pharmacological measures, e.g. corticosteroids, antihistamines. Given the side-effect profiles of these medications and the growing interest in complementary treatment modalities as part of integrative medical interventions, well known flavonoids, such as quercetin and catechin, are under investigation for topical and systemic application methods for relief. As flavonoid derivatives, pycnogenol and epigallocatechin gallate have alleviated dry eye symptoms, including lacrimal gland inflammation, tear secretion, and the stability of the tear film. Research on ocular cannabinoid receptors and response to synthetic cannabinoids are also being considered for therapy of anterior ocular disorders. The expansion of herbal formulations provides a framework for future treatment regimens for ocular surface disorders.

SUMMARY

Flavonoids and cannabinoids show promise as potential complementary treatment for allergic diseases because of their anti-inflammatory and antiallergic properties. Several studies implementing ocular and systemic application of these compounds show potential in becoming adjuvant treatment strategies for improving quality of life while also managing ocular surface disease processes.

Evaluation of Meibomian Gland Loss and Ocular Surface Changes in Patients with Mild and Moderate-to-Severe Graves' Ophthalmopathy

OBJECTIVES

To evaluate the association of Graves' Ophthalmopathy (GO) with the meibomian glands and investigate the relation of ocular surface changes with meibomian gland parameters in patients with GO.

METHODS

This prospective study included 44 eyes of 44 mild and moderate-to-severe GO patients and 38 eyes of 38 control subjects. After a complete ophthalmologic examination, patients were assessed according to the Clinical Activity Score (CAS). The area of meibomian gland loss and meibography score was evaluated using meibography (Sirius; CSO, Florence, Italy). Schirmer test, tear break-up time (TBUT) and Ocular Surface Disease Index (OSDI) scores were evaluated.

RESULTS

Mean meibomian gland dropout area was 26.29 ± 1.58% in the GO group and 14.46 ± 1.52% in the healthy controls (p < .001). Mean meibography score in the GO group was 2.61 ± 0.15 while it was 1.32 ± 0.25 in the healthy controls (p < .001). Meibomian gland dropout area was positively correlated with CAS and OSDI questionnaire results (p = .015, r = 0.391; p < .001, r = 0.662, respectively) and negatively correlated with TBUT and Schirmer test scores (p < .001, r = -0.635; p = .003, r = -0.474, respectively). Meibography score was positively correlated with CAS and OSDI questionnaire results (p = .012, r = 0.383; p = .007, r = 0.419, respectively) and negatively correlated with TBUT and Schirmer test scores (p = .002, r = -0.467; p = .023, r = -0.359, respectively).

CONCLUSION

Meibomian glands are quantitatively decreased in patients with GO. The decrease of meibomian glands is correlated with objective and subjective dry eye findings. Dry eye treatment in GO patients should include meibomian gland deficiency as well.