Association between dyslipidaemia and dry eye disease: a systematic review and meta-analysis

PURPOSE

To report a systematic review and meta-analysis of the association between dry eye disease (DED) and dyslipidaemia.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were systematically searched from January 2000 to December 2021. We included observational studies to assess the correlation of DED with meibomian gland dysfunction and dyslipidaemia without any language restrictions. The pooled OR with 95% CI was calculated in Stata V.15.

RESULTS

Of 6727 identified studies, 18 studies (21 databases) with a total of 2 663 126 patients were analysed in our meta-analysis. The results showed that DED risk was associated with dyslipidaemia (OR=1.53, 95% CI: 1.41 to 1.66, p=0.001), especially elevated total cholesterol levels (OR=1.57, 95% CI: 1.25 to 1.99, p<0.001), elevated low-density lipoprotein cholesterol levels (OR=1.13, 95% CI: 1.06 to 1.20, p<0.001) and high-density lipoprotein cholesterol levels (OR=1.06, 95% CI: 1.01 to 1.11, p<0.001), but not with serum triglyceride levels. Moreover, having a history of lipid-lowering drug use (OR=1.41, 95% CI: 1.19 to 1.67, p<0.001) was also found to be positively associated with DED risk.

CONCLUSIONS

The findings suggested that dyslipidaemia and lipid-lowering drug use might be associated with an increased risk of DED. More evidence is needed to confirm the findings by prospective studies.

PROSPERO REGISTRATION NUMBER

CRD42022296664.

Relationship between ocular surface pain and corneal nerve loss in dry eye diabetics: a cross-sectional study in Shenyang, China

BACKGROUND

Diabetes mellitus has been associated with increased dry eye disease (DED) and exacerbates DED pathology.

OBJECTIVE

To investigate the potential relationship between corneal nerve loss and ocular pain among diabetic patients with dry eye (DE).

DESIGN

A cross-sectional study.

SETTING

He Eye Specialist Hospital, Shenyang, China.

PARTICIPANTS

This study recruited 124 eyes of 62 diabetic patients diagnosed with DED between August and October 2022.

MAIN OUTCOME MEASURES

Best-corrected visual acuity, intraocular pressure, non-invasive tear breakup time, tear meniscus height, tear film lipid layer, conjunctival hyperaemia (redness score), conjunctivocorneal epithelial staining (CS score), central corneal sensitivity and vitro confocal corneal microscopy was assessed in all subjects. The Ocular Surface Disease Index Questionnaire assessed DE symptoms and ocular pain.

RESULTS

The study's final analysis included 26 patients (52 eyes) without ocular pain and 36 patients (72 eyes) with ocular pain. The corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD) and corneal nerve fibre length (CNFL) in patients with ocular pain were significantly lower than those without (p<0.001, p=0.004, and p<0.001, respectively). CNFD, CNBD and CNFL negatively correlated with ocular pain (r=-0.385, r=-0.260, r=-0.358, respectively). Moreover, CNFD, CNBD and CNFL have a significant (p<0.05) positive correlation with corneal sensitivity (r=0.523, r=0.330, r=0.421, respectively).

CONCLUSIONS

Corneal nerve loss was associated with ocular pain and decreased corneal sensitivity in diabetic patients with DE. Further studies into the neurological role of ocular surface diseases can elaborate diagnostics, prognosis and treatment of diabetic patients with DE.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05193331).

Contact lens-related complications in austere conditions among military personnel: a systematic review

INTRODUCTION

Military service personnel are required to deploy to austere environments where they are exposed to harsh conditions. Many service personnel continue to wear contact lenses when deployed as they are an effective alternative to spectacles by affording superior ergonomic functionality, although they are associated with significant complications. We aimed to explore the prevalence and type of contact lens-related complications among deployed service personnel worldwide.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. PubMed, Medline, CINAHL and EMBASE databases were searched for relevant articles published between 1950 and 2023. The keywords 'contact lens' and 'military' or 'army' or 'navy' or 'air force' and 'austere' or 'deployed' or 'adverse' were used.

RESULTS

Five eligible articles were included. Excluded articles reported contact lens wear in the firm base, were not related to military personnel or did not involve the deployed setting. Major complications associated with contact lens wear included microbial keratitis and contact lens-related discomfort. Excluding case reports, the overall incidence of contact lens-related complications ranged from 0.35% to 25.4%. The three case reports included in this systematic review described Acanthamoeba keratitis, Nocardia keratitis and contact lens-related discomfort as significant complications. These case reports also detailed time to initial presentation and type of contact lens worn when complications were encountered. Types of deployed conditions service personnel were exposed to included desert, temperate and underwater environments.

CONCLUSIONS

We highlight a scarcity of recent data regarding contact lens-related complications in the deployed setting. While contact lens-wearing service personnel are at risk of infectious keratitis and contact lens-related discomfort, we recommend good-quality data collection on contact lens wearing schedules and complication rates to steer guidance on contact lens wear in service personnel.

Protocol for a parallel assignment prospective, randomised, comparative trial to evaluate the safety and efficacy of intense pulsed light (IPL) combined with 3% diquafosol (DQS) ophthalmic solution in dry eye syndrome

INTRODUCTION

Evaporative dry eye (EDE) is common and can lead to ocular pain, decreased visual quality and reduced quality of life. Intense pulsed light (IPL) and 3% diquafosol ophthalmic solution have been found to be beneficial in reducing signs and symptoms of dry eye.

METHODS AND ANALYSIS

A randomised clinical trial will be performed at He Eye Specialist Hospital in Shenyang. 360 dry eye disease patients will be equally divided randomly into the IPL group, DQS group (3% diquafosol ophthalmic solution eye-drops) and IPL+group (IPL combined with 3% diquafosol eye-drops). All groups will be followed up for 4 weeks. The primary outcome measures will be the non-invasive tear break-up time and the Ocular Surface Disease Index change from the baseline. The secondary outcome measures willincludeconjunctival and cornea staining with fluorescein and lissamine, meibomian gland function and secretion quality, tear film lipid layer score, tear meniscus height, conjunctival hyperemia (redness score) changes . Adverse events also will be monitored and documented.

DISCUSSION

This study aimed to assess whether the combination of IPL with 3% diquafosol ophthalmic solution (study group), IPL+ (study group), is more effective than IPL (active control group) or DQS (active control group) in participants with EDE.

ETHICS AND DISSEMINATION

Management of dry eye with IPL combined with 3% diquafosol ophthalmic solution, registered on 23 January 2023. Ethics approval number: IRB (2022) K029.01. The study's findings will be shared regardless of the effect's direction.

TRIAL REGISTRATION NUMBER

NCT05694026.

Patient-reported burden and overall impact of dry eye disease across eight European countries: a cross-sectional web-based survey

OBJECTIVE

Dry eye disease (DED) is a multifactorial disease involving the tears and ocular surface. It impacts a patient's quality of life (QoL) and ability to perform daily activities. This study assessed the burden of self-reported DED among adults in eight European countries.

DESIGN

Online cross-sectional survey.

SETTING

General population in France, Italy, Germany, Greece, the Netherlands, Portugal, Spain and Sweden.

PARTICIPANTS

Adults aged ≥18 years with (n=6084) and without (n=6161) self-reported DED were recruited via emails and screened.

MAIN OUTCOME MEASURES

All participants completed National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) and EuroQol-5 Dimension-5 Level Questionnaire (EQ-5D-5L). All DED participants completed the Eye Dryness Score (EDS) Visual Analogue Scale, and Ocular Comfort Index and Work Productivity and Activity Impairment Questionnaire: Specific Health Problem questionnaires. In addition, half of the respondents with DED completed Survey A (Impact of Dry Eye on Everyday Life) and the other half completed Survey B (Standard Patient Evaluation of Eye Dryness Questionnaire) and Dry Eye Questionnaire-5.

RESULTS

Participants with self-reported DED had lower functional vision and lower overall health status than participants without self-reported DED as measured by the NEI-VFQ and EQ-5D-5L, respectively.Increasing self-reported DED severity as measured by the EDS was shown to correspond with worse symptom severity/frequency, lower functional vision, higher impact on work productivity, daily activities and QoL.

CONCLUSION

This study showed that patients' reported burden of self-reported DED was similar across the eight European countries. Those with self-reported DED reported lower health status and functional vision compared to those without self-reported DED and these parameters worsen with increasing disease severity.

Association of different digital media experiences with paediatric dry eye in China: a population-based study

OBJECTIVE

To investigate the ocular surface effects of different digital media experiences in Chinese elementary school students.

DESIGN

Population-based cross-sectional study was used.

SETTING

14 randomly selected primary schools in Yuhuatai District, Nanjing, China PARTICIPANTS: 2,694 students between 7 and 8-year-old.

OUTCOME MEASURES

Prevalence of and risk factors for different types of dry eye disease，and different digital media experience with different ocular signs.

RESULTS

The prevalence of 'symptomatic DED' was 8.7% (95% CI 7.6% to 9.8%) and 'definite DED' prevalence rate was 5.5% (95% CI 4.7% to 6.4%). In multivariable logistic regression model, allergic conjunctivitis (OR=4.33, 95% CI (3.01 to 6.23), p<0.001), more than 1 hour per day on outdoor activity (OR=0.69, 95% CI (0.49 to 0.99), p=0.043), smartphone (OR=2.73, 95% CI (1.51 to 4.91), p=0.001), tablet (OR=2.09, 95% CI (1.07 to 4.07), p=0.030) and homework (OR=1.86, 95% CI (1.22 to 2.83), p=0.004) were independently associated with 'definite DED', while allergic conjunctivitis (OR=5.58, 95% CI (4.12 to 7.55), p<0.001), more than 1 hour per day on outdoor activity (OR=0.72, 95% CI (0.53 to 0.97), p=0.028), smartphone (OR=2.60, 95% CI (1.55 to 4.35), p<0.001), tablet (OR=1.84, 95% CI (1.02 to 3.34), p=0.044) and homework (OR=2.57, 95% CI (1.84 to 3.60), p<0.001) were independently associated with 'symptomatic DED'.

CONCLUSIONS

Using smartphones or tablets for an average of more than 1 hour per day through the course of a year is independently associated with paediatric DED.

Effectiveness of interventions for dry eye: a protocol for an overview of systematic reviews

INTRODUCTION

Dry eye is a leading cause of ocular morbidity and economic and societal burden for patients and healthcare systems. There are several treatment options available for dry eye and high-quality systematic reviews synthesise the evidence for their effectiveness and potential harms.

METHODS AND ANALYSIS

We will search the Cochrane Eyes and Vision US satellite (CEV@US) database of eyes and vision systematic reviews for systematic reviews on interventions for dry eye. CEV@US conducted an initial search of PubMed and Embase to populate the CEV@US database of eyes and vision systematic reviews in 2007, which was updated most recently in August 2021. We will search the database for systematic reviews published since 1 January 2016 because systematic reviews more than 5 years are unlikely to be up to date. We will consider Cochrane and non-Cochrane systematic reviews eligible for inclusion. Two authors will independently screen articles. We will include studies that evaluate interventions for dry eye and/or meibomian gland dysfunction with no restriction on types of participants or review language. We will select reliable systematic reviews (ie, those meeting pre-established methodological criteria) for inclusion, assessed by one investigator and verified by a second investigator. We will extract ratings of the certainty of evidence from within each review. We will report the degree of overlap for systematic reviews that answer similar questions and include overlapping primary studies. We will present results of the overview in alignment with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions (Online Chapter 5: Overviews of Reviews), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and an overview of reviews quality and transparency checklist. The anticipated start and completion dates for this overview are 1 May 2021 and 30 April 2022, respectively.

ETHICS AND DISSEMINATION

This overview will not require the approval of an Ethics Committee because it will use published studies. We will publish results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021279880.

Prevalence of blindness and its determinants in Bangladeshi adult population: results from a national cross-sectional survey

OBJECTIVE

The objective of this study was to determine the prevalence of blindness and its determinants in Bangladeshi adult population.

STUDY DESIGN

A cross-sectional population-based survey conducted at household level with national representation. Samples were drawn from the 2011 national census frame using a multistage stratified cluster sampling method.

SETTING AND PARTICIPANTS

The survey was done in urban and rural areas in 2013 using a probability proportionate to size sampling approach to locate participants from 72 primary sampling units. One man or one woman aged ≥40 years was randomly selected from their households to recruit 7200. In addition to sociodemographic data, information on medication for hypertension and diabetes was obtained. Blood pressure and capillary blood glucose were measured. Eyelids, cornea, lens, and retina were examined in addition to visual acuity and refraction testing.

PRIMARY OUTCOME MEASURES

The following definition was used to categorise subjects having (1) blindness: visual acuity <3/60, (2) low vision: ≥3/60 to <6/60 and (3) normal vision: ≥6/12 after best correction.

RESULTS

We could recruit 6391 (88.8%) people among whom 2955 (46.2%) were men. Among them, 1922 (30.1%) were from urban and 4469 (69.9%) were from rural areas. The mean age was 54.3 (SD 11.2) years. The age-standardised prevalence, after best correction, of blindness and low vision was 1.0% (95% CI 0.5% to 1.4%) and 12.1% (95% CI 10.5% to 13.8%), respectively. Multivariable logistic regression indicated that cataract, age-related macular degeneration and diabetic retinopathy were significantly associated with low vision and blindness after adjustment for age and sex. Population attributable risk of cataract for low vision and blindness was 79.6%.

CONCLUSIONS

Low vision and blindness are common problems in those aged 40 years or older. Extensive screening and eye care services are necessary for wider coverage engaging all tiers of the healthcare system especially focusing on cataract.

Clinical efficacy of diquafosol sodium 3% versus hyaluronic acid 0.1% in patients with dry eye disease after cataract surgery: a protocol for a single-centre, randomised controlled trial

INTRODUCTION

The number of cataract surgeries, the most common ophthalmic surgery, is expected to increase due to ageing populations. Dry eye disease (DED) is a frequent side effect of cataract surgery, contributing to lower postoperative patient satisfaction and suboptimal quality of vision. It is unclear which eye-drops commonly used in these patients should be recommended for postoperative DED treatment. This study aims to compare the efficacy of topical administration of diquafosol sodium 3% vs hyaluronic acid 0.1% eye-drops in patients with DED after cataract surgery.

METHODS AND ANALYSIS

The study is designed as a single-blind randomised controlled trial. The participants will be randomly (1:1) allocated to either the diquafosol sodium 3% topical administration group (n=21) or the hyaluronic acid 0.1% topical administration group (n=21). Each group will receive its assigned eye-drop intervention over a 12-week period. The primary outcome will be measured using the total score of the Japanese version of the Ocular Surface Disease Index during the visit 5 weeks postoperatively. Both groups will be followed up after their respective eye-drop application for 12 weeks according to the intervention regimens. Secondary outcome measures including meibomian gland function assessment, tear film break-up time, keratoconjunctival staining score, maximum blink interval and tear secretion volume using Schirmer's test I will be assessed at 1, 5, 9, 13 and 25 weeks postoperatively.

ETHICS AND DISSEMINATION

This study has been approved by the Juntendo Hospital Certified Review Board, Tokyo, Japan (Approved protocol V.7.0 dated 7 May 2021. Approval number: J20-018) and has been registered with the Japan Registry of Clinical Trials. Written informed consent will be collected from every patient prior to study participation. The results of this trial will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

jRCT1031210018.

Prevalence and incidence of dry eye in the USA: a systematic review protocol

INTRODUCTION

Dry eye is a multifactorial chronic condition characterised by tear film insufficiency and instability, and ocular symptoms including foreign body sensation, itching, irritation, soreness and visual disturbance. The prevalence and incidence of dry eye are major determinants of the magnitude of economic and societal costs of the disease. This protocol proposes a systematic review and meta-analysis of the prevalence and incidence of dry eye in the USA.

METHODS AND ANALYSIS

Working with an information specialist, we will develop search strategies for Ovid Medline and Embase for population-based cross-sectional and cohort studies involving US-based populations that report the prevalence and/or incidence of dry eye. We will include studies involving persons of all ages from 1 January 2010 to the current date with no language restrictions. We will also hand-search references of included studies, dry eye epidemiology-related systematic reviews, clinical practice guidelines and literature provided by agencies and organisations. Two investigators will independently screen the titles and abstracts, and then full-text reports to determine eligibility. One investigator will extract study data and perform risk of bias assessments using tools designed specifically for prevalence and incidence studies. A second investigator will verify all extracted study data and risk of bias assessments. We will assess heterogeneity, qualitatively and quantitatively. When appropriate, we will meta-analyse prevalence and incidence estimates.

ETHICS AND DISSEMINATION

This review does not require approval by an ethics committee because it will use published studies. We will publish our results in a peer-reviewed journal and present at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021256934.

Prevalence of dry eye in patients with systemic lupus erythematosus: a meta-analysis

OBJECTIVES

To investigate dry eye disease (DED) in patients affected by systemic lupus erythematosus (SLE).

METHODS

We conducted a systematic search of the literature on PubMed, EMBASE and the Cochrane Library databases from conception to 30 April 2020 for studies related to dry eye, secondary Sjögren's syndrome (sSS) and SLE. Original full-text articles with the number of patients diagnosed with SLE of over 15 were included. The risk of bias was evaluated with a validated critical appraisal tool which assessed study quality based on confounding factors, selection bias, bias related to measurement and bias related to data analysis. Data were extracted and pooled to evaluate the overall prevalence of DED with the random-effect model and sSS with the fixed effect model.

RESULTS

A total of 29 studies were included and 18 273 participants were involved. The pooled data showed that the overall prevalence of DED was 16% (95% CI 10% to 21%, p<0.001) in patients of SLE. Dry eye symptoms and abnormal Schirmer's test were found in 26% (95% CI 20% to 32%, p<0.001) and 24% (95% CI 14% to 34%, p<0.001) of patients with SLE, respectively. 12% (95% CI 9% to 15%, p<0.001) of patients also met the criteria of sSS. The OR of DED in patients with SLE was 4.26 (95% CI 3.47 to 5.05, p<0.001) compared with healthy controls. The meta-regression analysis showed that the sample size (p=0.004) and study location (p=0.022) could be the source of heterogeneity.

CONCLUSIONS

DED and sSS are both common in patients with SLE.

Family refusal of eye tissue donation from potential solid organ donors: a retrospective analysis of summary and free-text data from the UK National Health Service Blood and Transplant Services (NHS-BT) National Referral Centre (1 April 2014 to 31 March 2017)

OBJECTIVES

Long-standing undersupply of eye tissue exists both in the UK and globally, and the UK National Health Service Blood and Transplant Service (NHSBT) has called for further research exploring barriers to eye donation. This study aims to: (1) describe reported reasons for non-donation of eye tissue from solid organ donors in the UK between 1 April 2014 and 31 March 2017 and (2) discuss these findings with respect to existing theories relating to non-donation of eyes by family members.

DESIGN

Secondary analysis of a national primary data set of recorded reasons for non-donation of eyes from 2790 potential solid organ donors. Data analysis including descriptive statistics and qualitative content analysis of free-text data for 126 recorded cases of family decline of eye donation.

SETTING

National data set covering solid organ donation (secondary care).

PARTICIPANTS

2790 potential organ donors were assessed for eye donation eligibility between 1 April 2014 and 31 March 2017.

RESULTS

Reasons for non-retrieval of eyes were recorded as: family wishes (n=1339, 48% of total cases); medical reasons (n=841, 30%); deceased wishes (n=180, 7%). In >50% of recorded cases, reasons for non-donation were based on family's knowledge of the deceased wishes, their perception of the deceased wishes and specific concerns regarding processes or effects of eye donation (for the deceased body). Findings are discussed with respect to the existing theoretical perspectives.

CONCLUSION

Eye donation involves distinct psychological and sociocultural factors for families and HCPs that have not been fully explored in research or integrated into service design. We propose areas for future research and service development including potential of only retrieving corneal discs as opposed to full eyes to reduce disfigurement concerns; public education regarding donation processes; exploration of how request processes potentially influence acceptance of eye donation; procedures for assessment of familial responses to information provided during consent conversations.

Comparison of treatment efficacy between 100% platelet-rich plasma and 100% serum eye drops in moderate-to-severe dry eye disease: a randomised controlled trial protocol

INTRODUCTION

Dry eye disease (DED) is a common eye problem. Although the disease is not fatal, it substantially reduces quality of life and creates a high economic burden, especially in patients with moderate-to-severe DED. Several biological tear substitutes (eg, autologous serum (AS), autologous platelet-rich plasma (APRP) and autologous platelet lysate) could effectively improve dry eyes. However, evidence on their comparative efficacy is controversial. This study aims to compare the efficacy of 100% APRP with 100% AS eye drops in patients with moderate-to-severe DED.

METHODS AND ANALYSIS

The study is a single-centre, double-blinded randomised, parallel, non-inferiority trial. One hundred and thirty patients with moderate-to-severe DED, aged 18-70 years will be recruited from outpatient clinic, Department of Ophthalmology, Ramathibodi Hospital, Bangkok from February 2021 to January 2023. Patients will be randomised to receive either 100% APRP or 100% AS eye drops (1:1 ratio) for 4 weeks. The primary outcomes are ocular surface disease index (OSDI) and ocular surface staining (OSS) evaluated using the Oxford scale. Secondary outcomes are fluorescein break-up time, Schirmer's I test, meibomian gland parameters and adverse events. Other measured outcomes include best-corrected visual acuity, intraocular pressure and compliance.

ETHICS AND DISSEMINATION

The study protocol and any supplements used in conducting this trial have been approved by the Ethics Committee of Faculty of Medicine, Ramathibodi Hospital, Mahidol University (MURA2020/1930). Informed consent will be obtained from all patients before study entry. Results will be presented in peer-reviewed journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT04683796.

Patient-reported burden of dry eye disease in the UK: a cross-sectional web-based survey

OBJECTIVES

To compare sociodemographics and vision-related quality of life (QoL) of individuals with or without dry eye disease (DED); and to explore the impact of DED symptom severity on visual function, activity limitations and work productivity.

DESIGN

Cross-sectional web-based survey.

SETTING

General UK population.

PARTICIPANTS

Adults ≥18 years with (N=1002) or without (N=1003) self-reported DED recruited through email and screened.

MAIN OUTCOME MEASURES

All participants completed the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), with six additional questions (items A3-A8), and the EuroQol 5 dimensions 5 levels. DED participants also completed Impact of Dry Eye on Everyday Life questionnaire, 5-item Dry Eye Questionnaire and the Standardised Patient Evaluation of Eye Dryness questionnaire along with the Ocular Comfort Index, Work Productivity and Activity Impairment and the Eye Dryness Score (EDS), a Visual Analogue Scale.

RESULTS

Baseline demographic and clinical characteristics were similar in participants with versus without DED (mean age, 55.2 vs 55.0 years; 61.8% vs 61.0% women, respectively) based on recruitment targets. Scores were derived from NEI VFQ-25 using the new 28-item revised VFQ (VFQ-28R) scoring. Mean (SD) VFQ-28R scores were lower in participants with versus without DED, indicating worse functioning (activity limitations, 73.3 (12.3) vs 84.4 (12.3); socioemotional functioning, 75.3 (21.5) vs 90.3 (16.2); total score, 71.6 (12.8) vs 83.6 (12.6)). Higher percentages of problems/inability to do activities were observed among those with versus without DED. The impact of DED on visual function was worse for participants with more severe DED symptoms, as assessed by EDS. In addition, a higher EDS was associated with worse symptoms on common DED scales and a worse impact on work productivity.

CONCLUSIONS

DED symptoms were associated with negative effects on visual function, activities and work productivity, whereas worse DED symptoms had a greater impact on vision-related QoL and work productivity.

WASH Upgrades for Health in Amhara (WUHA): study protocol for a cluster-randomised trial in Ethiopia

INTRODUCTION

Facial hygiene promotion and environmental improvements are central components of the global trachoma elimination strategy despite a lack of experimental evidence supporting the effectiveness of water, sanitation and hygiene (WASH) measures for reducing trachoma transmission. The objective of the WUHA (WASH Upgrades for Health in Amhara) trial is to evaluate if a comprehensive water improvement and hygiene education programme reduces the prevalence of ocular chlamydia infection in rural Africa.

METHODS AND ANALYSIS

Forty study clusters, each of which had received at least annual mass azithromycin distributions for the 7 years prior to the start of the study, are randomised in a 1:1 ratio to the WASH intervention arm or a delayed WASH arm. The WASH package includes a community water point, community-based hygiene promotion workers, household wash stations, household WASH education books, household soap distribution and a primary school hygiene curriculum. Educational activities emphasise face-washing and latrine use. Mass antibiotic distributions are not provided during the first 3 years but are provided annually over the final 4 years of the trial. Annual monitoring visits are conducted in each community. The primary outcome is PCR evidence of ocular chlamydia infection among children aged 0-5 years, measured in a separate random sample of children annually over 7 years. A secondary outcome is improvement of the clinical signs of trachoma between the baseline and final study visits as assessed by conjunctival photography. Laboratory workers and photo-graders are masked to treatment allocation.

ETHICS AND DISSEMINATION

Study protocols have been approved by human subjects review boards at the University of California, San Francisco, Emory University, the Ethiopian Food and Drug Authority, and the Ethiopian Ministry of Innovation and Technology. A data safety and monitoring committee oversees the trial. Results will be disseminated through peer-reviewed publications and presentations.

TRIAL REGISTRATION NUMBER

(http://www.clinicaltrials.gov): NCT02754583; Pre-results.

Assault-related severe ocular chemical injury at a London ophthalmic referral hospital: a 3-year retrospective observational study

OBJECTIVES

To understand the incidence, causes, management and outcomes of intentional (assault) and unintentional severe ocular chemical injuries (SOCI) at an urban tertiary referral centre in the UK.

DESIGN

Retrospective observational study.

SETTING

A London tertiary referral ophthalmic centre, Moorfields Eye Hospital.

PARTICIPANTS

All cases of SOCI presenting between 1 September 2011 and 31 August 2014 were identified. The definition of SOCI was grade 3 or 4 on the Hughes-Roper-Hall classification system. We identified 25 cases (6 in 2011-2012, 8 in 2012-2013, 11 in 2013-2014). Median age was 31.1 years. 23 cases (92%) were male.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of cases of SOCI caused by assault, per year. Secondary outcome measures included the number of cases of SOCI, injury characteristics and mechanism, initial and long-term management, visual outcome and the need for surgical intervention.

RESULTS

Between 2011 and 2012, 3/6 cases were due to assault (50%); between 2012 and 2013, 7/8 were due to assault (87.5%); and between 2013 and 2014, 6/11 were due to assault (54.4%). Assault was responsible for 16/25 (64%) cases overall, while 8/25 (32%) cases were work related. The causative agent was known to be alkali in 16/25 (64%), while 10/25 (40%) did not complete the follow-up. The mean number of clock hours of limbal ischaemia was 5.24 (SD 2.97). 17/25 (68%) were Hughes-Roper-Hall grade 3. Surgical intervention occurred in 1/25. The final best-corrected visual acuity was 6/12 or worse in 11/25 (44%) and was counting fingers or worse in 4/25 (16%).

CONCLUSIONS

Previous studies found that SOCI had a low incidence and that work-related injuries were the most common cause. Our study demonstrates an increasing incidence of SOCI, which may be accounted for by a rise in assault using corrosive substances. A high number of patients did not attend regularly for follow-up and visual outcomes from these injuries are poor.

Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial

INTRODUCTION

Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively.

METHODS AND ANALYSIS

We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF).

ETHICS AND DISSEMINATION

The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ISRCTN14332621; pre-results.

Risk of recurrent corneal erosion in patients with diabetes mellitus in Taiwan: a population-based cohort study

OBJECTIVE

To investigate the risk of recurrent corneal erosion (RCE) in patients with diabetes mellitus (DM).

DESIGN, SETTING AND PARTICIPANTS

This retrospective, nationwide, matched cohort study included 239 854 patients with DM recruited between 2003 and 2005 from the Longitudinal Cohort of Diabetes Patients database. The control group included the same number of age-matched and sex-matched patients without DM selected from the Taiwan Longitudinal Health Insurance Database, 2000. Data for each patient were collected from the index date until December 2013.

MAIN OUTCOMES AND MEASURES

The incidence and risk of RCE were compared between the two groups. Cox proportional hazards regression was used to calculate the HR for RCE after adjustment for potential confounders. The cumulative RCE incidence rate was calculated using Kaplan-Meier analysis.

RESULTS

In total, 1236 patients with DM and 884 controls developed RCE during the follow-up period, resulting in an incidence rate of RCE in patients with DM (5.87/10 000 person-years (PY)) higher than that in the controls (4.23/10 000 PY). After adjustment for potential confounders, including hypertension, hyperlipidaemia, chronic renal disease and keratoconjunctivitis sicca, patients with DM were 1.35 times (95% CI, 1.24 to 1.48) more likely to develop RCE than the total sample cohort.

CONCLUSIONS

DM increases the risk of RCE, which is an interdisciplinary issue. Therefore, close collaboration between endocrinologists and ophthalmologists is important in managing RCE following DM.

Difluprednate versus Prednisolone Acetate after Cataract Surgery: a Systematic Review and Meta-Analysis

OBJECTIVE

Topical steroids are the cornerstone in controlling the inflammation after cataract surgery. Prednisolone acetate and difluprednate are the two main products for this purpose. However, it is unclear which one should be used in terms of effectiveness and safety.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline via PubMed, Cochrane Central Register of Controlled Trials, Web of science and clinicaltrials.gov were searched through 10 January 2018, and updated on 20 July 2019, in addition to researching the references' lists of the relevant articles.

ELIGIBILITY CRITERIA

Randomised-controlled trials (RCTs) comparing difluprednate and prednisolone acetate regardless of the dosing regimen used.

DATA EXTRACTION AND SYNTHESIS

Two independent authors assessed the included RCTs regarding the risk of bias using the Cochrane tool. Relevant data were extracted, and meta-analysis was conducted using a random-effects model. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to appraise the evidence quality.

RESULTS

We included six RCTs with 883 patients: 441 received difluprednate and 442 received prednisolone acetate. The evidence quality was graded as moderate for corneal oedema and intraocular pressure and low for anterior chamber (AC) clearance. After small incision cataract surgery, difluprednate was superior in clearing AC cells at 1 week (OR=2.5, p>0.00001) and at 2 weeks (OR=2.5, p=0.04), as well as clearing the AC flare at 2 weeks (OR=6.7, p=0.04). After phacoemulsification, difluprednate was superior in terms of corneal clarity at 1 day (OR=2.6, p=0.02) and 1 week after surgery (OR=1.96, p=0.0007). No statistically significant difference was detected between both agents at 1 month in effectiveness. Also, both agents were safe, evaluated by the ocular hypertension (OR=1.23, p=0.8).

CONCLUSION

With low-to-moderate certainty, difluprednate and prednisolone acetate are safe agents for controlling the inflammation after cataract surgery. Difluprednate showed significant superiority in terms of AC cells and AC flare at 2 weeks postoperatively.

Transepithelial versus epithelium-off corneal collagen cross-linking for corneal ectasia: protocol for a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials

INTRODUCTION

Corneal ectasias are progressive, degenerative ocular diseases defined by abnormal structural changes in the cornea, leading to distortion of vision and substantial reduction in quality of life. Corneal collagen cross-linking (CXL) increases the biomechanical rigidity of the cornea and has been shown to halt ectatic processes. The established CXL protocol requires removal of the corneal epithelium. However, some surgeons have proposed transepithelial approaches to enhance patient recovery and minimise adverse events. Whether novel transepithelial approaches are as effective in arresting ectasia as the established epithelium-off protocol remains unclear. This study will systematically review the evidence on transepithelial CXL approaches and compare it to the epithelium-off protocol.

METHODS AND ANALYSIS

We will include randomised controlled trials (RCTs) comparing transepithelial and epithelium-off CXL for any corneal ectasia. We will search 16 electronic databases including MEDLINE and Embase, as well as the grey literature. Two reviewers will independently screen search results to identify eligible studies, complete data abstraction and conduct quality assessment. We will assess the quality of individual RCTs using the Cochrane risk of bias assessment tool. Our primary outcome will be the change in maximal keratometry at 12 months after treatment, and we will examine 11 additional outcomes. We will summarise our analyses by measures of association (relative risk or odds ratio) and corresponding 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences with 95% CIs for continuous outcomes. Prespecified subgroup analyses will be conducted to explore heterogeneity. The overall quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review as it draws from previously published data. Results of the study will be submitted to a peer-reviewed journal for publication and discussed at conferences and seminars.

PROSPERO REGISTRATION NUMBER

CRD42018102069.

Village-Integrated Eye Worker trial (VIEW): rationale and design of a cluster-randomised trial to prevent corneal ulcers in resource-limited settings

INTRODUCTION

Corneal opacity is a leading cause of blindness worldwide. In resource-limited settings, untreated traumatic corneal abrasions may result in infection and ultimately, opacity. Although antimicrobial treatment of corneal ulcers may successfully cure infections, the scarring that accompanies the resolution of infection can still result in visual impairment. Prevention may be the optimal approach for reducing corneal blindness. Studies have employed community health workers to provide prompt administration of antimicrobials after corneal abrasions to prevent infections, but these studies were not designed to determine the effectiveness of such a programme.

METHODS AND ANALYSIS

The Village-Integrated Eye Worker trial (VIEW) is a cluster-randomised trial designed to assess the effectiveness of a community health worker intervention to prevent corneal ulcers. Twenty-four Village Development Committees (VDCs) in Nepal were randomised to receive a corneal ulcer prevention programme or to no intervention. Female Community Health Volunteers (FCHVs) in intervention VDCs are trained to diagnose corneal abrasions, provide antimicrobials and to refer participants when needed. An annual census is conducted over 3 years in all study VDCs to assess the incidence of corneal ulceration via corneal photography (primary outcome). Masked outcome assessors grade corneal photographs to determine the presence or absence of incident corneal opacities. The primary analysis is negative binomial regression to compare the incidence of corneal ulceration by study arm.

ETHICS AND DISSEMINATION

The University of California San Francisco Committee on Human Research, Nepal Netra Jyoti Sangh and the Nepal Health Research Council have given ethical approval for the trial. The results of this trial will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

NCT01969786; Pre-results.

Surgical efficiency in femtosecond laser cataract surgery compared with phacoemulsification cataract surgery: a case-control study

OBJECTIVES

To investigate differences in surgical time, the distance the surgical instrument travelled and number of movements required to complete manual phacoemulsification cataract surgery versus femtosecond laser cataract surgery.

DESIGN

Non-randomised comparative case series.

SETTING

Single surgery site, Moorfields Eye Hospital, UK.

PARTICIPANTS

40 cataract surgeries of 40 patients.

INTERVENTIONS

Laser-assisted and manual phacoemulsification cataract surgery. Laser-assisted surgery cases were performed using the AMO Catalys platform.

PRIMARY AND SECONDARY OUTCOME MEASURES

Computer vision tracking software PhacoTracking were applied to the recordings to establish the distance the instrument travelled, total number of movements (the number of times an instrument stops and starts moving) and time taken for surgery steps including phacoemulsification, irrigation-aspiration (IA) and overall surgery time. The time taken for laser docking and delivery was not included in the analyses.

RESULTS

Data on 19 laser-assisted and 19 manual phacoemulsification surgeries were analysed (two cases were excluded due to insufficient video-recording quality). There were no differences in the number of instrument moves, the distance the instrument travelled or time taken to complete the phacoemulsification stage. However for IA, the number of instrument moves (manual: mean 20 (SD 15) vs laser: mean 38 (SD 22), P=0.008) and time taken (manual: mean 75 s (SD 24) vs laser: mean 108 s (SD 36), P=0.003) were significantly greater for laser cases. For laser versus manual cases overall, there was no difference in number of moves or the distance the instrument travelled, but laser cases took longer (mean 88 s, P=0.049).

CONCLUSIONS

Laser cataract surgery cases took longer to complete without accounting for the time taken to complete the laser procedure itself. This appears to be in part due to IA requiring more instrument manoeuvres and taking longer to complete. Data from a large randomised series would better elucidate this relationship.

Laser scanning in vivo confocal microscopy (IVCM) for evaluating human corneal sub-basal nerve plexus parameters: protocol for a systematic review

INTRODUCTION

Laser scanning in vivo confocal microscopy (IVCM) enables non-invasive, high-resolution imaging of the cornea. In recent years, there has been a vast increase in researchers using laser scanning IVCM to image and quantify corneal nerve parameters. However, a range of methodological approaches have been adopted. The primary aim of this systematic review is to critically appraise the reported method(s) of primary research studies that have used laser scanning IVCM to quantify corneal sub-basal nerve plexus (SBNP) parameters in humans, and to examine corneal nerve parameters in healthy individuals.

METHODS AND ANALYSIS

A systematic review of primary studies that have used laser scanning IVCM to quantify SBNP parameters in humans will be conducted. Comprehensive electronic searches will be performed in Ovid MedLine, Embase and the Cochrane Library. Two reviewers will independently assess titles and abstracts, and exclude studies not meeting the inclusion criteria. For studies judged eligible or potentially eligible, full texts will be independently assessed by two reviewers to determine eligibility. A third reviewer will resolve any discrepancies in judgement. Risk of bias will be assessed using a custom tool, covering five methodological domains: participant selection, method of image capture, method of image analysis, data reporting and other sources of bias. A systematic narrative synthesis of findings will be provided. A multilevel random-effects meta-analysis will be performed for corneal nerve parameters derived from healthy participants. This review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

ETHICS AND DISSEMINATION

As this review considers published data, ethical approval is not required. We foresee that this synthesis will serve as a reference for future studies, and can be used to inform best practice standards for using IVCM in clinical research. A manuscript reporting the results of the review will be published and may also be presented at scientific conferences.

Prevalence and risk factors of eye diseases in adult patients with obstructive sleep apnoea: results from the SLE.E.P.Y cohort study

OBJECTIVES

To assess the occurrence of glaucoma, eyelid, corneal and macular disorders in a cohort of patients with obstructive sleep apnoea (OSA) diagnosed by overnight polysomnography and to investigate into the risk factors for the above eye diseases (EDs).

DESIGN

Cross-sectional cohort study between 2014 and 2015.

SETTING

Unit of Respiratory Medicine and Eye Clinic of the University of Verona.

PARTICIPANTS

431 consecutive patients were considered eligible. Of these, 87 declined to participate, 35 were untraceable and 13 were deceased.

INTERVENTIONS

A complete ophthalmic evaluation of both eyes for each patient.

PRIMARY AND SECONDARY OUTCOME MEASURES

Best-corrected distance visual acuity, intraocular pressure, corneal, macular and optic nerve optical coherence tomography, ocular aberrometry, optic nerve laser polarimetry, visual field test, and eyelid examination.

RESULTS

296 patients aged 64.5±12.8 years, 23% female and 77% male, underwent ophthalmic examination. There was 56% (n=166) prevalence of eyelid disorders, 27% (n=80) of corneal disorders, 13% (n=39) of macular disorders and 11% (n=33) of glaucoma. Advancing age was not associated with the severity of OSA, while significant differences were found for gender, body mass index, Oxygen Desaturation Index, smoking habit, hypertension and diabetes. Severe OSA was significantly associated with glaucoma (OR, 95% CI 1.05 to 5.93, p=0.037).

CONCLUSIONS

EDs were more prevalent in our patinets with OSA than in the general population. Severe Apnoea/Hypopnoea Index level seemed to play a role as risk factor only for glaucoma.