Assessment and management of dry eye disease in the UK: standardising reality-based best practice.

: Dry eye disease is a common ophthalmic condition which is chronic in nature, It is major health issue especially in the current digital era. Dry eye disease is one of the most common reasons for visiting eye care practitioners. To understand the treatment pattern of medical management of dry eye disease across India.This single visit, cross-sectional, non-interventional, interview-based ophthalmologist survey on dry eye disease (DED) was conducted between 10-13 May 2023 at 81st Annual Conference of All India Ophthalmological Society, Kochi–AIOC 2023. A total of 71 registered ophthalmologist from all over India attending AIOC 2023 who were willing to provide their written consent participated in the survey and completed structured questionnaire on dry eye disease management. Approximately 39.44% ophthalmologist have 20-40% of patients who visiting to daily OPD are suffering from DED, and 40.85% ophthalmologist said the percentage is even more i.e. between 40-60%. 88.73% ophthalmologist responded environmental factors such as digital use specially increased usage of computers and mobile are responsible for dry eye. 49.30% patients suffered from aqueous - deficient dry eye (ADDE) and remaining 50.70% evaporative dry eye (EDE). Artificial Tears (AT) is the first line in management of DED said by all ophthalmologist & in certain cases, depending on type, severity, and cause of dry eye other drugs like cyclosporine, corticosteroids, antioxidant supplements and other medications might be used. Viscosity, pH and osmolarity are important for artificial tear said by 77.46% of ophthalmologist & 23% ophthalmologist opine that viscosity is major factor. 50% ophthalmologist believes that carboxymethylcellulose is the most suitable ingredient followed by sodium hyaluronate (29.58%). 61.43% Ophthalmologists replied, AT should provide continues relief from dry eye symptoms. 42.86% said AT should be used for long terms, it should be preservative free replied by 58.57% Ophthalmologists and 40% replied acceptance from patient should be there in terms of cost. Tear substitutes are the most commonly prescribed medications for the management of dry eye disease. Artificial tears are amongst the first-line agents in the management options for the management of dry eye disease, because of their ease for usage, with a better safety and tolerability profile and their availability in various formulations.

Purpose: Diagnosis and management of dry eye disease (DED) differ across clinics due to the variable diagnostic and treatment equipment and the lack of guidelines for managing DED. This study aims to understand the current landscape of DED diagnosis and management in the Malaysian healthcare setting, as well as to evaluate the feasibility of implementing a DED framework in local settings. Study design: A quantitative cross-sectional survey. Methods: A 12-question multiple-choice questionnaire was administered to 13 local cornea specialists from May 2023 to September 2023. The questionnaire comprised of six dimensions: guidelines utilisation for DED diagnosis and management; standardisation for DED diagnosis and management between clinics; administration of validated DED questionnaire to patient; availability of clinical and screening tests in their clinics; treatment availability in their clinics; and follow-up and patient education. Results: Most respondents (84.6%) use one or more international guidelines or national guidelines from other countries in their clinical practice. All respondents agreed that DED diagnosis and management should be standardised among ophthalmologists, while 92.3% would consider implementing a standardised DED diagnosis and management algorithm in their practice. More than two-thirds of the respondents (69.2%) do not have the resources for their patients to self-administer DED questionnaire. All respondents have slit-lamp examination, fluorescein tear film breakup time test and corneal fluorescein staining as screening tools, as well as ocular lubricants, cyclosporine A and corticosteroids as treatment options in their clinics. Most respondents (92.3%) were able to follow-up with their patients at least every six months. Less than half of the respondents (38.5%) were able to spend an average of 13 minutes for patient education. Conclusion: This study revealed that most of the local cornea specialists would consider implementing a standardised DED framework in managing their patients with DED. However, factors impeding its implementation (e.g. diagnostic and treatment equipment availability, cost and clinical workflow differences, and patient loads) in local settings should be identified and tackled to standardise DED management and improve the quality of patient care in Malaysia.

BackgroundAn impaired ocular surface presents substantial challenges in terms of planning for cataract surgery. As a multifactorial ocular disorder, dry eye disease (DED) is common in the general population and prevalent in patients scheduled for lens replacement surgery. Cataract surgery can exacerbate DED and worsen several ocular parameters. Timely diagnosis and appropriate treatment of DED are vital to ensuring positive ophthalmic surgical outcomes.This consensus report of the Taiwan Society of Cataract and Refractive Surgeons (TSCRS) regarding the management of DED before, during, and after cataract surgery highlights the gaps between clinical guidelines and several aspects of DED, including diagnostic testing, diagnostic criteria, and clinical practice treatment.MethodsAn expert panel of five specialists in the field of ophthalmology was recruited to develop consensus statements regarding the management of DED in both the general population and in patients undergoing cataract surgery in Taiwan. Two separate meetings of the five specialists, who were endorsed by the TSCRS, were convened for this purpose. A survey questionnaire consisting of binary or multiple-choice questions was developed through a consensus-driven formulation process. A percentage value was calculated for each statement, and a minimum of 60% agreement (equivalent to three out of five members) was required to achieve consensus. The second discussion meeting involved the presentation of the finalized consensus statements and concluded the consensus development process. Lastly, the finalized consensus statements were approved by all the experts, and the formulated recommendations for DED in the general population and prospective cataract surgery patients were accordingly presented.ResultsThe optimal algorithm for managing DED in the general population and in patients scheduled for cataract surgery was developed to address the unmet needs of this cohort in Taiwan.ConclusionThis report provides recommendations for managing dry eye disease. It is essential to screen and confirm DED through endorsed questionnaires and tests and then diagnose it. Treatment and management of DED should follow a stepwise approach. Screening and diagnosing DED is also recommended before cataract surgery. After cataract surgery, relatively aggressive treatment strategies are recommended to manage DED effectively.

ABSTRACTPurpose: To evaluate the role of topical chloroquine (CHQ) as an adjunct to topical lubricants in the management of mild-moderate dry eye disease (DED)Methods: Prospective comparative pilot study allocated 150 patients with symptoms of mild to moderate DED to receive topical CMC 0.5% three times a day (group I, n = 75) or topical CHQ 0.03% twice a day with carboxymethylcellulose (CMC) 0.5% three times a day (group II, n = 75), for three months. Primary outcome measures were ocular surface disease index (OSDI) score and conjunctival impression cytology at 3 months. Secondary outcome measures were TBUT, Schirmer’s test, ocular surface staining and any adverse effects at 3 months. Follow up was performed at 1 and 3 months.Results: At three months, the OSDI score was significantly better in the CHQ group as compared with the CMC group (CMC-18.36 ± 4.03 (SD), CHQ group- 15.9 ± 5.18 (SD); p = .002). Nelson’s score was 0.92 ± 0.69 (SD) in the CHQ group as compared with 1.60 ± 0.77 (SD) in the CMC group (p < .001). Abnormal impression cytology was observed in 20% cases in the CHQ group as compared with 61.3% cases in CMC group (p < .001). A significant correlation was observed between Nelson’s score and OSDI (Spearman’s rho correlation coefficient 0.414, p < .001). TBUT, Schirmer test and ocular surface staining were significantly better in the CHQ group (p < .001). No adverse effects were observed in any group.Conclusion: Topical chloroquine is a useful adjunct to topical lubricants in the management of DED as it decreases the underlying chronic inflammation and helps maintain ocular surface stability.

Dry eye disease (DED) is a continuing medical challenge, further worsened in the autoimmune inflammatory hyperactivation milieu of Sjögren's syndrome (SS) due to disturbances to innate and adaptive immunity with malfunctioning neuro-endocrine control. However, the pathogenetic mechanisms of SS DED are not fully established. This review summarized the available evidence, from systematic reviews, meta-analyses, and randomized clinical trials, for the efficacy and safety of the available ocular therapeutics for the management of SS DED. Relevant studies were obtained from major databases using appropriate keywords. The available largely empirical symptomatic, supportive, and restorative treatments have significant limitations as they do not alter local and systemic disease progression. Topical therapies have expanded to include biologics, surgical approaches, scleral lens fitting, the management of lid margin disease, systemic treatments, nutritional support, and the transplantation of stem cells. They are not curative, as they cannot permanently restore the ocular surface's homeostasis. These approaches are efficacious in the short term in most studies, with more significant variability in outcome measures among studies in the long term. This review offers an interdisciplinary perspective that enriches our understanding of SS DED. This updated review addresses current knowledge gaps and identifies promising areas for future research to overcome this medical challenge.

Although the ultimate goal of dry eye disease (DED) management is to restore the ocular surface and tear film homeostasis and address any accompanying symptoms, addressing this is not an easy task. Despite the wide range of current treatment modalities targeting multiple aspects of DED, the available DED management literature is quite heterogeneous, rendering evaluation or comparison of treatment outcomes hard or almost impossible. There is still a shortage of well-designed, large-scale, nonsponsored, randomized, controlled trials (RCTs) evaluating long-term safety and efficacy of many targeted therapies individually or used in combination, in the treatment of identified subgroups of patients with DED. This review focuses on the treatment modalities in DED management and aims to reveal the current evidence available as deduced from the outcomes of RCTs.

New Korean guidelines for the diagnosis and management of dry eye disease were developed based on literature reviews by the Korean Dry Eye Guideline Establishment Committee, a previous dry eye guideline by Korean Corneal Disease Study Group, a survey of Korean Dry Eye Society (KDES) members, and KDES consensus meetings. The new definition of dry eye was also proposed by KDES regular members. The new definition by the regular members of the KDES is as follows: “Dry eye is a disease of the ocular surface characterized by tear film abnormalities and ocular symptoms.” The combination of ocular symptoms and an unstable tear film (tear breakup time <7 seconds) was considered as essential components for the diagnosis of dry eye. Schirmer test and ocular surface staining were considered adjunctive diagnostic criteria. The treatment guidelines consisted of a simplified stepwise approach according to aqueous deficiency dominant, evaporation dominant, and altered tear distribution subtypes. New Korean guidelines can be used as a simple, valid, and accessible tool for the diagnosis and management of dry eye disease in clinical practice.

To evaluate signs and symptoms in patients diagnosed with dry eye disease (DED), divided into dry eye (DE) groups, in order to find a new biomarker that allows an accurate diagnosis, management and classification of DED. This cross-sectional, observational study included 71 DED subjects. Subjective symptoms, visual quality and DE signs were assessed using the Ocular Surface Disease Index (OSDI), the Quality of Vision (QoV) questionnaire, best corrected distance visual acuity (VA), functional visual acuity (FVA), contrast sensitivity (CS), high- and low-order corneal aberrations (HOA and LOA, respectively), tear break-up time (TBUT), Meibomian Gland Dysfunction (MGD), Schirmer test, corneal staining, lid wiper epitheliopathy (LWE) and meibography. Participants were classified into three groups based on dryness severity using a cluster analysis, i.e., mild (N = 17, 55.8 ± 15.4 years), moderate (N = 41, 63.5 ± 10.6 years) and severe (N = 13, 65.0 ± 12.0). A new Dry Eye Severity Index (DESI) based on ocular surface signs has been developed and its association with symptoms, visual quality and signs was assessed. Comparisons between groups were made using Kruskal-Wallis and Chi-squared tests. Spearman correlation analysis was also performed. The DESI was based on three tests for DE signs: TBUT, Schirmer test and MGD. The DESI showed significant differences between different pairs of groups: Mild Dryness versus Moderate Dryness (p < 0.001), Mild Dryness versus Severe Dryness (p < 0.001) and Moderate Dryness versus Severe Dryness (p < 0.001). The DESI was significantly correlated with age (rho = -0.30; p = 0.01), OSDI score (rho = -0.32; p = 0.007), QoV score (rho = -0.35; p = 0.003), VA (rho = -0.34; p = 0.003), FVA (rho = -0.38; p = 0.001) and CS (rho = 0.42; p < 0.001) Also, significant differences between the severity groups were found for OSDI and QoV scores, VA, FVA, CS and MGD (p < 0.05). The DESI has good performance as a biomarker for the diagnosis, classification and management of DED.

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

To explore Malaysian community pharmacists' (CP) challenges in identifying and managing dry eye disease (DED) and opportunities to optimize DED care, as previous studies reported inconsistencies in DED identification by community pharmacy staff, and few publications describe Malaysian CP views on DED management in community pharmacy settings. Using the Social Ecological Theory for Community Health Promotion, individual in-depth interviews were conducted (May-June 2023) with 20 CP in Malaysia's Klang Valley. Participants with diverse DED management experiences were recruited using purposive and snowball sampling until data saturation. Interviews were audio-recorded, transcribed, independently coded by two researchers, and thematically analysed. CP faced 12 challenges in identifying and managing DED: patient-related (brand rigidity, 'quick fix' attitude, inadequate health literacy, and self-efficacy skills), provider-related (imprecise assessment, referral difficulties, knowledge gaps), therapeutics-related (short shelf life, affordability), and pharmacy-related (limited manpower, inadequate private consultation space, low eye health visibility). The 12 opportunities for optimizing DED care were community-related (eye health education, holistic approaches, public awareness), profession-related (decision-support mobile health applications integrated with evidence-based DED management protocols to streamline consultation processes, interdisciplinary collaborations), industry-related (pharmaceutical and medical device advancements, comparative data on medication value, promotion of proactive management), and organization-related (management-mandated resource allocation, ancillary staff education, and expanded products and services). Malaysian CP encountered challenges in identifying and managing DED. Knowledge sharing and collaborations with ophthalmologists improve DED management by CP, while clinicians can stay updated on medication-related recommendations and treatment adherence. The role of digital health in these processes requires further study.

To understand current clinical management of dry eye disease (DED), based on its perceived severity and subtype, by practitioners across the world. The content of the anonymous survey was chosen to reflect the DED management strategies reported by the Tear Film and Ocular Surface Society (TFOS) second Dry Eye Workshop (DEWS II). Questions were designed to ascertain practitioner treatment choice, depending on the subtype and severity of DED. It was first created in English and then translated/back-translated into 14 languages for online completion. Completed surveys were received from 905 eye care practitioners (52% optometrists and 42% ophthalmologists) from across the globe. Many treatment strategies for DED were observed to be utilised by respondents, independent of severity and subtype, the most common being advice (82%), low (82%) and high (81%) viscosity unpreserved lubricants and lid wipes/scrubs (79%). Several treatments were prescribed across all severity levels (scaled from 1 mild to 10 severe), such as advice (median 4.5, range 4.8), artificial tears (median 5.1, range 4.6) and nutritional supplements (median 5.3, range 4.2). Others were prescribed more frequently with increasing disease severity, for instance, biologics (median 8.2, range 2.8) and surgical approaches (median 8.1, range 2.2). While a similar number of practitioners reported prescribing advice, artificial tears and anti-inflammatories regardless of DED subtype, the commonly reported approaches for aqueous deficient DED were punctal occlusion, therapeutic contact lenses and secretagogues, while the use of oral essential fatty acids, topical lipid-containing products, lid hygiene and lid warming were the preferred management choices for evaporative DED. There remains great variability in clinical approaches to DED management and until research-evidence definitively informs improved guidance, data from this survey may be useful for clinicians to benchmark their practice.

The application of a new continuous functional visual acuity measurement system in dry eye syndromes

PurposeTo evaluate the effect of once daily administration of chitosan-N-acetylcysteine (Lacrimera®) in the management of dry eye disease (DED).MethodsEighteen patients (3 male, 15 female) aged 25–86 years (mean 61.1) and suffering from moderate to severe DED with superficial punctate keratitis (SPK) were retrospectively evaluated after a trial of Lacrimera® drops (1 drop in the morning for 5 days only). All the patients were using other artificial tears before the treatment. All lubricants were stopped, and Lacrimera® was started instead. Slit-lamp examination and images were taken before and at 1 and 3 weeks follow-up after the treatment. The subjective (Ocular Surface Disease Index, OSDI) and objective (Oxford Grading System, OGS) evaluation was recorded. A paired student’s t test was performed to analyse the data.ResultsAt baseline, the SPK grade was I to IV (OGS) and the OSDI ranged from 25 to 71.4. Fifteen patients showed a statistically significant (p < 0.0001) improvement in OGS and the OSDI at 3 weeks post-treatment. Three patients showed no improvement.ConclusionsA single-dose instillation of chitosan-N-acetylcysteine for five consecutive days improved signs and symptoms in patients affected from DED from a variety of causes, who were refractory to standard treatment with lubricants. Given its posology, the absence of side effects and the results obtained Lacrimera® should be taken into consideration as a viable option in patients with moderate to severe DED.

PurposeSuccessful management of dry eye disease depends upon an effective two-way communication between eyecare practitioners and affected patients. However, there has been limited investigation into the perspectives of patients with dry eye disease in the United Kingdom regarding their risk factors and desired treatment outcomes. MethodsAn online, self-administered, anonymous survey was distributed to patients based in the United Kingdom who have had a diagnosis of dry eye disease between November 2023 to March 2024. The survey consisted of four main sections including demographics, the 5-item Dry Eye Questionnaire (DEQ-5), and Likert scales rating the likelihood of various risk factors contributing to their dry eyes and the desired treatment outcomes in various components of signs and symptoms. ResultsThe survey was completed by 152 respondents (mean age 51.7 ± 16.7 years, 103 females). Respondents rated environmental conditions the highest in terms of likelihood of contributing to their dry eye disease [median (interquartile range): 7.5 (5–10)], followed by digital device use [7 (4–9)] and poor sleep quality [4 (1–7)]. In terms of desired treatment outcomes, symptom frequency and severity as well as tear stability were ranked the highest in importance [10 (8–10)]. ConclusionsThis survey demonstrated the perceptions of dry eye patients in the United Kingdom regarding lifestyle or modifiable risk factors contributing to their dry eye disease, as well as the most important treatment outcomes of these patients. These aspects should be considered by clinicians in the management of dry eye disease, as well as researchers particularly when designing studies which investigate treatment effects of current and novel dry eye interventions

The purpose of this study was to examine the effectiveness of omega-3 fatty acids in comparison to a placebo in the management of dry eye disease. A systematic literature search was performed including randomised controlled trials (RCTs) comparing omega-3 versus placebo in the management of dry eye disease in human subjects. There were no language or time restrictions. Eligible trials were assessed for bias and assigned a risk-of-bias score. Data extraction was carried out using a standardised data extraction form, and meta-analysis was performed using a random effects model for continuous data. The outcome measures were Ocular Surface Disease Index (OSDI) scores, tear breakup time (TBUT) measurements, corneal staining and Schirmer's score. Statistical heterogeneity was defined as substantial if the I2 test achieved a value >60%. Eight parallel RCTs including 1107 subjects met eligibility criteria. None of the included studies achieved low risk of bias. Data synthesis demonstrated an improvement in the mean change in OSDI score from baseline to final assessment. Omega-3 supplementation conferred no evident improvement in corneal staining, TBUT or Schirmer's score. There was considerable statistical heterogeneity in all four outcome measures. This updated systematic review and meta-analysis indicates that omega-3 supplementation improves subjective symptoms in patients with dry eye disease.