The Influence of Lid-Parallel Conjunctival Folds and Conjunctivochalasis on Dry Eye Symptoms with and Without Contact Lens Wear: A Review of the Literature

INTRODUCTION

Lid-parallel conjunctival folds (LIPCOF) and conjunctivochalasis (CCH) are similar conditions that seem to be related to dry eye severity. In addition, there is a lack of studies on the topic of LIPCOF and CCH on dry eye symptoms in non-contact lens and contact lens (CL) wearers. Therefore, the aim of this study is to review the relationship of LIPCOF and CCH with dry eye symptoms in non-CL and CL wearers, as well as to report the treatment of dry eye disease (DED) in non-CL and CL wearers who present LIPCOF or CCH.

METHODS

A literature review of full-length original studies in two databases, PubMed and Scopus, was performed. The search period included observational studies in humans published between April 21, 2009 and March 20, 2023.

RESULTS

A total of 26 studies were included. The studies suggest that LIPCOF and CCH are significantly related to dry eye symptoms in non-CL and CL wearers. However, the impact of CL wear on LIPCOF and CCH may be complex and may vary depending on individual factors such as lens type, lens care regimen, and pre-existing ocular conditions. Regarding LIPCOF management, tear substitutes seem to significantly reduce LIPCOF and dry eye symptoms in non-CL wearers, while vectored thermal pulsation (VTP) and microblepharoexfoliation (MBE) are suggested as promising treatment for LIPCOF and dry eye symptoms in CL wearers. Regarding CCH management, surgical interventions may be effective in reducing CCH when medical treatments have no response. In addition, an ocular examination by slit lamp is necessary to distinguish both conditions.

CONCLUSIONS

Tear substitutes, VTP, MBE, and fitting CLs with low coefficient of friction (CoF) seem to reduce and prevent LIPCOF. However, surgical treatment options seem to be more effective in the complete elimination of CCH. An adequate evaluation and differentiation between LIPCOF and CCH are important, and they should be considered by practitioners in managing dry eye symptoms in non-CL and CL wearers.

Multi-symptom Relief with Propylene Glycol-Hydroxypropyl-Guar Nanoemulsion Lubricant Eye Drops in Subjects with Dry Eye Disease: A Post-Marketing Prospective Study

INTRODUCTION

The study aimed to evaluate multi-symptom relief of dry eye manifestations with the use of propylene glycol-hydroxypropyl-guar (PG-HPG) nanoemulsion lubricant eye drops, among subjects with dry eye disease (DED).

METHODS

This was a post-marketing, prospective, single-arm study conducted in the USA. Subjects aged ≥ 18 years, with tear breakup time (TBUT) ≤ 10 s for both eyes, dry eye questionnaire-5 (DEQ-5) "watery eyes" symptom score 1-4, symptoms of burning/stinging, sore and tired eyes as determined by impact of dry eye on everyday living-symptom bother (IDEEL-SB) questionnaire, and IDEEL-SB score 16-65 were included. Subjects were required to complete IDEEL-SB and DEQ-5 at days 0, 14 ± 2, and 28 ± 2, and self-administer one drop of PG-HPG four times daily for 28 ± 2 days. Primary endpoints were change from baseline at day 28 in symptoms of sore, stinging/burning, and tired eyes on IDEEL-SB; and symptom of watery eyes on DEQ-5. Other endpoints evaluated were corneal staining and TBUT at baseline and day 28 ± 2; symptom relief (5-point Likert scale) at day 28 ± 2, and safety.

RESULTS

Of 119 subjects enrolled, 95 completed the study (mean ± SD age 61.2 ± 13.0 years; female 69.5%). Mean IDEEL-SB scores reduced significantly from baseline at day 28 for symptoms of aching/sore eyes (change from baseline - 1.0 ± 1.1), burning/stinging eyes (change from baseline - 1.1 ± 0.9), and tired eyes (change from baseline - 1.1 ± 1.0) (all p < 0.0001). Mean DEQ-5 score for watery eye symptoms significantly reduced from baseline at day 28 (change from baseline - 0.9 ± 1.0, p < 0.0001). Corneal staining at day 28 was comparable to baseline. TBUT improved from baseline to day 28. On a Likert scale, more than 50% of subjects reported relief from symptoms of sore, stinging, and burning eyes. Three (3.1%) subjects reported treatment-emergent adverse events (non-ocular).

CONCLUSIONS

PG-HPG nanoemulsion lubricant eye drops significantly improved multiple dry eye symptoms in subjects with DED over 28 days, with no new safety concerns.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier, NCT05056155.

The effects of breaks on digital eye strain, dry eye and binocular vision: Testing the 20-20-20 rule

PURPOSE

To evaluate the benefits on the eyes of taking breaks based on the 20-20-20 rule.

METHODS

Bespoke computer software using the laptop webcam to assess user breaks, eye gaze and blinking, and emitting personalized reminders of breaks based on the 20-20-20 rule, was downloaded onto the laptops of 29 symptomatic computer users. Digital eye strain (DES), binocular vision and dry eye were assessed before and after two weeks of using the reminders and one week after the discontinuation of the strategy. Binocular measurements included visual acuity, accommodative posture, stereopsis, fixation disparity, ocular alignment, accommodative facility, positive/negative vergences and near point of convergence. Symptoms were evaluated using the computer vision syndrome questionnaire, ocular surface disease index (OSDI), and symptom assessment in dry eye questionnaire (SANDE) versions one and two. Dry eye signs were assessed by measuring tear meniscus height, conjunctival redness, blink rate and incomplete blinking, lipid layer thickness, non-invasive keratograph break-up time, corneal and conjunctival staining and lid wiper epitheliopathy.

RESULTS

A decrease in the duration of computer work and the duration of breaks, along with an increase in the number of breaks taken per day was observed as a result of the 20-20-20 rule reminders (p ≤ 0.015). No changes on any binocular parameter were observed after the management period (p ≥ 0.051), except for an increase in accommodative facility (p = 0.010). Dry eye symptoms and DES decreased with the rule reminders (p ≤ 0.045), although this improvement was not maintained one week after discontinuation (p > 0.05). No changes on any ocular surface and tear film parameter were observed with the rule reminders (p ≥ 0.089).

CONCLUSIONS

The 20-20-20 rule is an effective strategy for reducing DES and dry eye symptoms, although 2 weeks was not enough to considerably improve binocular vision or dry eye signs.

Evaluation of daily disposable senofilcon A contact lenses in a symptomatic population

PURPOSE

To evaluate the comfort performance of ACUVUE OASYS® 1-Day with HydraLuxe™ Technology among symptomatic contact lens wearers by using Contact Lens User Experience (CLUE) comfort scores and Contact Lens Dry Eye Questionnaire 8 (CLDEQ-8) discomfort and dryness scores.

METHODS

Three clinical trials evaluated comfort and dryness when refitting symptomatic contact lens wearers to ACUVUE OASYS® 1-Day with HydraLuxe™ lenses. This analysis combined the CLUE comfort and CLDEQ-8 scores obtained at baseline and 2-week follow-up and compared average scores between visits. Subjects were grouped by habitual lens modality (daily disposable or daily wear reusable) and habitual lens material (silicone hydrogel or hydrogel). The analysis included data from 107 subjects.

RESULTS

Significant increases in mean CLUE comfort scores between baseline and 2-week follow-up occurred in all subject groups across habitual lens modality and material, indicating an improvement in overall comfort. CLUE comfort score improved clinically (≥5-point increase) among 75.7% of subjects (81/107). Similarly, significant decrease in mean CLDEQ-8 scores between baseline and 2-week follow-up occurred in all subject groups, indicating a decrease in the prevalence of dryness and discomfort symptoms. CLDEQ-8 score improved clinically (≥3-point reduction) among 82.2% of subjects (88/107). A majority of subjects (57.0%) became asymptomatic (CLDEQ-8 score ≤ 11 points) after 2 weeks of bilateral wear.

CONCLUSION

Refitting symptomatic contact lens patients to ACUVUE OASYS® 1-Day with HydraLuxe™ can improve overall comfort and reduce symptoms of dryness and discomfort, irrespective of the previous lens modality or habitual lens material.

Impact of E-Schooling on Digital Eye Strain in Coronavirus Disease Era: A Survey of 654 Students

Purpose:

To assess digital eye strain (DES) among schoolchildren during lockdown.

Methods:

An online questionnaire-based, cross-sectional study was conducted. A validated, self-administered, electronic questionnaire was circulated among students of 5–18 years of age. The duration of data collection was from May 18, 2020 to May 24, 2020. Rasch-based Computer-Vision Symptom Scale was deployed to measure the DES.

Results:

A total of 654 students (mean age: 12.02 ± 3.9 years) completed the survey. The average per day digital device exposure was 5.2 ± 2.2 h. A total of 507 (92.8%) children reported experiencing at least one asthenopic/dry eye symptom (AS/DS). The most prevalent symptoms were eye redness (69.1%) and heaviness of eyelids (79.7%). Significant positive correlation was reported between age and per day duration of digital device exposure (Pearson correlation 0.25; P < 0.001). Computer vision syndrome (CVS) score for spectacle users was significantly higher (P < 0.001). CVS score was found to correlate significantly with age and duration of digital device exposure (P < 0.001).

Conclusion:

Most of the students surveyed, experienced at least one symptom of DS or AS, indicating a need to educate them about the possible deleterious effects and help them adapt to the currently evolving education system.

Meibomian gland dysfunction is the primary determinant of dry eye symptoms: Analysis of 2346 patients

PURPOSE

To determine relative contributions of various ocular surface clinical signs and predisposing factors to the magnitude of dry eye symptoms.

METHODS

Clinical audit data were prospectively collected for newly referred dry eye patients. All 2346 patients had an initial visit evaluation of the Ocular Surface Disease Index (OSDI), and a detailed ophthalmic examination including tear breakup time (TBUT), ocular surface fluorescein staining, Schirmer's I test. Among the participants, 1414 had number of liquid meibum expressing glands (NLMEG) evaluated on standard force expression. Other variables collected included history of glaucoma or glaucoma surgery, and history of allergies.

RESULTS

In patients aged 46.2 ± 14.8 years, 77.4% were women and 87.1% Chinese. The mean ± SD OSDI was 35.2 ± 21.7. On univariate analysis, higher OSDI was associated with glaucoma diagnosis (p = 0.003), glaucoma surgery (p = 0.002), greater temporal corneal staining (p = 0.002), reduced NLMEG (p < 0.001), and higher inferior forniceal papillary grade (p < 0.001). OSDI was not significantly associated with gender, TBUT, Schirmer's I test values, or the use of cyclosporine eyedrops. On multivariate regression, higher OSDI scores were associated with fewer NLMEG (p = 0.002) and increased lower eyelid forniceal papillary grading (p = 0.002). Corneal staining, glaucoma status and glaucoma surgery were not significantly associated with OSDI. Logistic regression showed that severe symptoms (OSDI>32) was associated with <2 NLMEG [OR(95%CI): 1.34(1.08-1.66)], and presence of inferior eyelid forniceal papillae [1.50(1.17-1.91)].

CONCLUSIONS

Meibomian gland dysfunction (MGD) and lower forniceal papillary reaction had significant contributions to the severity of symptoms, in contrast to traditional dry eye signs. MGD should be objectively assessed and treated to improve symptoms.

Symptoms of ocular surface disease in construction workers: comparative study with office workers

Background

To investigate and contrast the prevalence of dry eye symptoms in construction workers and office workers using the OSDI questionnaire.

Methods

A cross-sectional, observational study was conducted using the OSDI questionnaire to evaluate dry eye symptoms and associated risk factors. Sampled size calculation with a power of 80% and a 95% degree of confidence suggested the inclusion of 298 participants.

Results

We studied 304 subjects (149 construction workers and 155 office workers). More than half (55%) of the participants presented dry eye symptoms (OSDI > 12). The average OSDI score was 21.30 ± 22.20 points, being lower in the group of construction workers (12.45 ± 17.50) than in-office workers (28.51 ± 22.99) (p <  0.001). Considering participants who had moderate and severe symptoms (23 to 100 points in OSDI), office workers presented dry eye symptoms 4.15 times more frequently than construction workers (OR 4.15, 95% CI 2.52, 6.85). Women presented statistical evidence of higher OSDI scores than men (32.47 ± 23.72 vs. 14.87 ± 18.48, respectively).

Conclusions

construction workers have four times less risk of presenting dry eye symptoms than people working in the average office space. This highlights the pernicious effects on the ocular surface of the office environment, which poses a significant risk for the development or worsening of dry eye symptoms.

Dry eye symptoms and signs in children wearing OK lenses for six months in China

BACKGROUND

This study aims to investigate symptoms of dry eye and signs of ocular surface disease in children with myopia during OK lens wear.

METHODS

A total of 68 subjects were prospectively managed with OK lens correction. These subjects were 8-14 years of age with myopia -0.50 to -5.00 dioptres of sphere and astigmatism of≤1.00 dioptres of cylinder. Patients with any ocular disease were ruled out from this study. All subjects completed a dry eye symptom questionnaire for OSDI scoring, corneal fluorescein staining, tear film break up time (TBUT) test and Schirmer's test I during the follow-up period. The follow-up period includes the primary visit (baseline), and at one day, one week, one month and six months after wearing the lens.

RESULTS

In terms of dry eye symptoms, we found that OSDI scores were significantly high after one day of wearing the lens (P<0.05). Additionally, TBUT values significantly decreased after one day (P<0.01) and one week (P<0.05) of wearing the OK lens. Corneal staining grade also significantly increased after one day and one week of wearing the OK lens. Furthermore, Schirmer's Test I values slightly, but not significantly, increased after one day and one week of wearing the lens. All variables returned to pre-wear levels at one month after wearing the lens, which remained stable up to six months of wearing the OK lens.

CONCLUSION

Our study is the first reveal that OK lens wear in children leads to dry eye symptoms and disturbs the tear film during the initial period of OK lens wear. However, this did not significantly interfere with tear secretion during the follow-up period.

Conjunctival MUC5AC+ goblet cell index: relationship with corneal nerves and dry eye

PURPOSE

To evaluate the relative proportion of conjunctival MUC5AC+ and MUC5AC- goblet cells in a post-LASIK population and their association with dry eye indicators and corneal nerve morphology using a MUC5AC+ Goblet Cell Index.

METHODS

Twenty subjects who had undergone LASIK > 12 months previously and 20 age-matched controls were recruited. Dry eye symptoms, tear breakup time, osmolarity, meniscus area and corneal nerve morphology were examined. Conjunctival impression cytology samples were collected from inferior-temporal bulbar conjunctiva using Millicell® inserts. Total goblet cell density was determined from positive cytokeratin-7 (CK7) immunolabelling; MUC5AC+ goblet cell density was determined from both CK7+- and MUC5AC+-immunolabelled cells. The ratio of MUC5AC+ to total density was defined as the "MUC5AC+ Goblet Cell Index". Differences in variables between groups and the associations between goblet cell variables and clinical assessments were examined.

RESULTS

No significant differences in the total and MUC5AC+ goblet cell density and tear film parameters were found between groups, although greater ocular discomfort was reported in the post-LASIK group (P = 0.02). A higher MUC5AC+ Index was associated with worse/greater dry eye symptoms (ρ = 0.55, P = 0.01) and higher nerve tortuosity (ρ = 0.57, P = 0.01) in the post-LASIK group; lower nerve density and thickness was found in controls (ρ > -0.45, P < 0.05), but not associated with tear film parameters.

CONCLUSIONS

The MUC5AC+ Goblet Cell Index provides an indicator of mucin secretion for assessing the goblet cell function in dry eye. In the post-LASIK participants, we found an increased MUC5AC+ Index associated with worse dry eye symptoms and adverse changes in corneal nerve morphology.

Ocular Demodex folliculorum: prevalence and associated symptoms in an Irish population

PURPOSE

To investigate the prevalence of ocular Demodex folliculorum (DF) in an Irish population. To validate a modified Ocular Surface Disease Index questionnaire and employ it to evaluate the relationship between dry eye symptoms and the presence of DF.

METHODS

One hundred and fifty-six subjects were enrolled in an epidemiological cross-sectional prevalence study. Each subject completed a novel questionnaire on ocular symptoms and was assessed for the presence of DF. Data was analysed to assess prevalence and to search for significant links between each symptom and DF.

RESULTS

An overall prevalence of 68% was found. Total mean number of DF found on microscopic examination was 3.83 mites per subject (range 0-25). The presence of symptoms was higher among individuals with DF (P = 0.04). Itch was found to be the symptom most significantly associated with the presence and number of DF (P = 0.025 and P = 0.035, respectively). The questionnaire showed good internal consistency (Cronbach's alpha; α > 0.7) and good reliability (Intra-class Correlation Co-efficient; ICC > 0.7). The sensitivity and specificity of a positive symptom result using the questionnaire were 70.8% and 46.9%, respectively.

CONCLUSION

There is a strong association between the prevalence of DF and symptoms, in particular itchy eyes. However, not all patients with DF will be symptomatic. The newly developed questionnaire is a reliable instrument for measuring change in symptoms over a period of time and suitable for observing patient reported outcomes in interventional treatment studies.

Impact of oral vitamin D supplementation on the ocular surface in people with dry eye and/or low serum vitamin D

PURPOSE

To determine the possible association between serum vitamin D levels and dry eye symptoms, and the impact of an oral vitamin D supplement.

METHODS

Three linked studies were performed. (i) 29 older adult participants, (ii) 29 dry eyed participants, and (iii) 2-month vitamin D supplementation for 32 dry eyed/low serum vitamin D levelled participants. All participants were assessed by the Ocular Surface Diseases Index (OSDI) to determine dry eye symptoms, and the phenol red thread test (PRT) and/or Schirmer's tear test, tear meniscus height, non-invasive tear break up time, grading ocular surface redness and fluorescein staining of the cornea to detect the tear quality and ocular surface conditions. Blood samples were collected for serum vitamin D analysis and interleukin-6 (IL-6) levels.

RESULTS

Among older adult participants, vitamin D levels were negatively correlated with dry eye symptoms, the severity of dry eye, and associated with tired eye symptom. Vitamin D levels of people with dry eye diagnosis were not correlated with OSDI scores and IL-6 levels; while IL-6 levels showed correlation with tear production. In supplement study, vitamin D levels increased by 29mol/l, while dry eye symptoms and grading of corneal staining appeared significant reductions. No significant changes in IL-6 levels.

CONCLUSIONS

Low vitamin D levels (<50nmol/l) were associated with dry eye symptoms in older individuals but not those diagnosed with dry eye. Vitamin D supplement increased the vitamin D levels, and improved dry eye symptoms, the tear quality and ocular surface conditions.

Neuropathic Ocular Pain due to Dry Eye is Associated with Multiple Comorbid Chronic Pain Syndromes

Recent data show that dry eye (DE) susceptibility and other chronic pain syndromes (CPS) such as chronic widespread pain, irritable bowel syndrome, and pelvic pain, might share common heritable factors. Previously, we showed that DE patients described more severe symptoms and tended to report features of neuropathic ocular pain (NOP). We hypothesized that patients with a greater number of CPS would have a different DE phenotype compared with those with fewer CPS. We recruited a cohort of 154 DE patients from the Miami Veterans Affairs Hospital and defined high and low CPS groups using cluster analysis. In addition to worse nonocular pain complaints and higher post-traumatic stress disorder and depression scores (P < .01), we found that the high CPS group reported more severe neuropathic type DE symptoms compared with the low CPS group, including worse ocular pain assessed via 3 different pain scales (P < .05), with similar objective corneal DE signs. To our knowledge, this was the first study to show that DE patients who manifest a greater number of comorbid CPS reported more severe DE symptoms and features of NOP. These findings provided further evidence that NOP might represent a central pain disorder, and that shared mechanistic factors might underlie vulnerability to some forms of DE and other comorbid CPS.

PERSPECTIVE

DE patients reported more frequent CPS (high CPS group) and reported worse DE symptoms and ocular and nonocular pain scores. The high CPS group reported symptoms of NOP that share causal genetic factors with comorbid CPS. These results imply that an NOP evaluation and treatment should be considered for DE patients.