Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review.

Purpose: To compare the effects of 2% rebamipide eye drop monotherapy versus in combination with 0.15% hyaluronic acid eye drops on dry eye syndrome following cataract surgery.Methods: One week post-cataract surgery, patients with dry eye syndrome were randomly assigned to receive either rebamipide monotherapy or a combination therapy with hyaluronic acid. Evaluations were conducted at 1 week, 1 month, and 2 months postoperatively, including strip meniscometry, tear breakup time, conjunctival and corneal staining, tear meniscus height, tear lipid layer thickness, and the ocular surface disease index.Results: In the rebamipide monotherapy group, significant improvements in tear breakup time were observed at 1 month (<i>p</i> = 0.049) and 2 months (<i>p</i> < 0.001) post-surgery, with additional improvements in ocular surface staining (<i>p</i> = 0.010) and ocular surface disease index (<i>p</i> = 0.007) at 2 months. In the combination therapy group, significant improvements in tear breakup time and staining were observed at both 1 and 2 months (tear breakup time: <i>p</i> < 0.001, < 0.001; staining: <i>p</i> = 0.001, < 0.001, respectively). However, strip meniscometry and ocular surface disease index scores worsened at 2 months (<i>p</i> = 0.004, 0.012, respectively). Compared to the rebamipide-only group, the combination group demonstrated higher tear breakup time, lower tear meniscus height, a higher ocular surface disease index score, and reduced corneal lipid layer thickness at 1 month (<i>p</i> = 0.014, 0.028, 0.004, 0.043, respectively). By 2 months, the combination group exhibited lower strip meniscometry scores and a higher ocular surface disease index (<i>p</i> = 0.001, < 0.001).Conclusions: The combined use of rebamipide and hyaluronic acid eye drops after cataract surgery showed benefits for dry eye syndrome, particularly with improvements in tear breakup time and corneal staining.

Objective: Long term use of preservative-containing medications has been associated with the development or worsening of ocular surface disease (OSD). This study aimed to determine the prevalence of OSD in glaucoma patients on long-term antiglaucoma medications. Methods: A cross-sectional hospital-based study was carried out on 208 respondents using Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), and Schirmer 1 test. Data analysis was done using Statistical Package for Social Science version 22.0 (SPSS Inc, Chicago, Illinois, USA). Results: The prevalence of OSD was higher in those on antiglaucoma medication using all modalities of assessment. Prevalence of OSD in glaucoma patients on antiglaucoma drugs was highest using TBUT- 69.2% (P = 0.031), with OSDI questionnaire it was 62.5% (P = 0.005), and it was lowest for Schirmer 1 test - 59.6%. For those nonglaucoma cases/not on any antiglaucoma medication, the prevalence using TBUT was 42.3%, using OSDI it was 16.3%, and with Schirmer 1 test it was 25.9%. Prevalence also increased with the increase in the number of eye drops from 1 to 2 drops/day using all modalities of assessment (P = 0.004). Using multivariate analysis, adjusting for sex and age, subjects who instilled 2 drops/day had four to five times the odds of having OSD. Conclusion: The prevalence of OSD is higher in patients with glaucoma on topical antiglaucoma medication than the nonglaucoma population studied and this increased with the increase in number of drops per day.

To describe dry eye disease in French elderly subjects. The Alienor Study is a population-based study on age-related eye disease in 963 residents of Bordeaux (France), aged 73 years or more. Self-reported dry eye disease and use of artificial tears were documented through face-to-face interview. Dry eye symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire and tear film stability by tear break-up time measurements (TBUT). Definite dry eye disease was defined as self-reported dry eye, confirmed by use of artificial tears and/or OSDI greater or equal to 22. Nine hundred and fifteen subjects, with mean age of 80 ± 4 years, returned the OSDI questionnaire. Of these, 271 (29.6%) subjects reported a dry eye disease and 135 (14.7%) were using artificial tears. An OSDI score > 22 was found in 359 (39.2%) subjects and a TBUT < 5 seconds in 335/746 (44.9%) subjects. Overall, definite dry eye affected 21.9% of subjects and was more frequent in women (27.1%) than in men (13.6%). After multivariate adjustment, dry eye disease was also significantly less frequent in subjects with high educational level (odds ratio (OR) = 0.49, 95% confidence interval (CI): 0.31-0.78 for long secondary school) and more frequent in subjects with ocular hypertension (OR = 1.61, 95% CI: 1.02-2.57) and those using anxiolytics (OR = 1.53, 95% CI: 1.02-2.29). This large observational study confirmed the high prevalence of dry eye symptoms among elderly subjects and confirmed some of the previously identified risk factors (in particular female gender and use of anxiolytics).

PurposeThe goal of this study was to evaluate the effect of thermal pulsation treatment on tear film parameters, specifically osmolarity and matrix metalloproteinase-9 (MMP-9), in patients with meibomian gland dysfunction (MGD) and dry eye disease (DED).MethodsA single-center review of 189 eyes that underwent thermal pulsation treatment was performed. Data were collected on pre and posttreatment osmolarity, MMP-9, tear break-up time (TBUT), and ocular surface disease index (OSDI) score. Statistical analyses were performed to detect any significant differences after treatment.ResultsThermal pulsation treatment led to significant improvements in TBUT (mean increase from 4.5 to 8.5 seconds [P<0.001]), OSDI score (mean decrease from 50.5 to 41.6 [P=0.024]), and MMP-9 (50% positive rate pretreatment compared to 26% positive rate post treatment [P<0.0001]). In the subset of patients who had a baseline osmolarity >307 mOsm/L (ie, diagnostic for DED), there was a significant improvement in the mean tear osmolarity from 317.1 to 306.6 mOsms/L after treatment (P=0.002).ConclusionTreating MGD is an important component of caring for the DED patient. Thermal pulsation treatment can improve MMP-9 levels on the ocular surface of patients with MGD and DED, as well as improve osmolarity in those with abnormal initial values. The present study suggests that meibomian glands play an important role in tear film dynamics and, as such, effective therapy such as thermal pulsation treatment aimed at improving meibomian gland health, can aid the restoration of normal tear film parameters and decrease patient symptoms of DED and MGD.

Objectives:This survey study of ophthalmologists investigated the prevalence and clinical manifestations of ocular surface disease (OSD) in glaucoma patients, assessment methods used, risk factors, glaucoma drugs considered responsible, and treatment approaches.Materials and Methods:A questionnaire prepared jointly by the Turkish Ophthalmological Association Cornea and Ocular Surface Society and Glaucoma Society using SurveyMonkey was sent to ophthalmologists via e-mail. The distribution of parameters was compared with chi-square test and p<0.05 was considered statistically significant.Results:Forty-five percent of the ophthalmologists reported that OSD was evident in least 25% of their patients. The most common symptom was redness (91.9%), while the most common ocular surface finding was conjunctival hyperemia (75.6%). The tests considered to be the most important in ocular surface assessment were ocular staining (38.7%) and tear film break-up time (TBUT) (21.9%). Ninety percent of the physicians stated that the main cause of OSD was benzalkonium chloride (BAC) in medications. Prostaglandin analogs and alpha-2 agonists were reported to be the most common medications causing OSD. In case of OSD, the ophthalmologists often switch to a glaucoma drug from a different group (38%), a non-preservative glaucoma drug (33.7%) or a drug with a preservative other than BAC (20.4%). Most physicians prescribed artificial tears (84.6%).Conclusion:In this cross-sectional survey study, ophthalmologists detected varying rates of OSD in glaucoma patients depending on chronic drug use and BAC exposure. Although ocular surface examination was performed by physicians, tests such as TBUT and ocular surface staining were rarely used. Detecting OSD in glaucoma patients and planning personalized treatment increase patient comfort, drug compliance, and treatment effectiveness. For this reason, it is important to prepare an algorithm for the management of comorbid OSD in glaucoma patients.

To assess whether meibomian glands and ocular surface parameters are affected by repeated topical povidone-iodine and antibiotic applications in patients with repeated intravitreal injections. Forty-five patients with at least three previous intravitreal injections and 28 healthy controls were included in the study. In the injection group, 21 patients had age-related macular degeneration and 24 patients had diabetic macular edema. For each participant, infrared meibography for the upper and lower eyelids and noninvasive tear break-up time calculation were performed with a corneal topographer. Fluorescein tear break-up time and ocular surface disease index (OSDI) scores were also obtained. Noninvasive tear break-up time, fluorescein tear break-up time, and OSDI scores were recorded for each participant and compared between the injection and control groups. These parameters were also compared as a subgroup analysis between patients with age-related macular degeneration (AMD) and diabetic macular edema (DME). Upper lid meibomian gland loss, lower lid meibomian gland loss ratios, and OSDI scores were significantly higher in the intravitreal injection group compared with the control group (P=0.004, P<0.001, P<0.001, respectively). Fluorescein tear break-up time and noninvasive tear break-up time were significantly lower in the intravitreal injection group compared with the control group (P<0.001, P<0.001). There was no significant difference between the AMD and DME groups for these parameters. This study showed for the first time that meibomian gland losses were significantly increased by repeated povidone-iodine and antibiotic applications in patients with repeated intravitreal injections. Ocular surface parameters were altered with higher ocular surface symptoms in those patients.

Purpose This study aimed to assess the efficacy of a platelet-rich plasma (PRP) injection into the lacrimal gland in severe dry eye and to compare it with preservative-free artificial tears. Patients and methods This study included a total of 74 eyes of 40 patients divided into two groups. The intervention group received three PRP injections transcutaneously in the region of the lacrimal gland. The control group was treated with preservative-free artificial tears. Results The intervention group showed improvement in all measured parameters, except the Meibomian gland score, with a statistically significant improvement in the Ocular Surface Disease Index (OSDI) score (P&lt;0.001) and the Schirmer test (P=0.011) and less significant improvement in the ocular surface staining score (P=0.076) and tear breakup time (TBUT) (P=0.09). Compared with the control group, the PRP intervention group showed a statistically significant improvement in the OSDI score (P&lt;0.001), the Schirmer test (P=0.005) and the ocular surface staining score (P=0.013) and less significant improvement in TBUT (P=0.2). Conclusion The use of PRP injections is safe and effective, with improvement in the OSDI, Schirmer test, and ocular surface staining and less improvement in TBUT, but it is not effective in improving Meibomian gland function.

The aim of this study was to evaluate the role of topical human IgG eye drops (4 mg/mL) as adjunct therapy in eyes with moderate to severe refractory dry eye disease (DED). A prospective, longitudinal, open label, dual cohort study of patients with chronic DED of moderate to severe grade comprise of OSIG therapy group cohort on topical immunoglobulin IgG 0.4% four times daily, as adjunctive therapy for one year, to study the role of OSIG therapy in comparison with conventional treatment. Patients above 18 years of age with chronic moderate to severe grade DED with tear break-up time (TBUT) ≤7 seconds, Schirmer test ≤9 mm/5 minutes, ocular surface disease index (OSDI) score ≥13, National Eye Institute (NEI) corneal staining score >3, and conjunctival staining score >3 were recruited into the study. Study participants in the conventional treatment cohort group were on topical lubricants four hourly (carboxymethyl cellulose 0.5% and lubricant ointment at bedtime), topical steroids (prednisolone 1%/fluorometholone 0.1%/loteprednol 0.5%) therapy as per the severity of the DED requirement and topical immunomodulators (cyclosporine A 0.1% eye drops or tacrolimus 0.1% eye ointment) twice daily. Study participants in the OSIG treatment cohort group were started on topical human immunoglobulin IgG 0.4% four times daily as adjunct therapy in addition to the all the above-mentioned medications for a period of 12 months. Study parameters included DED severity level assessment, NIH score, ocular surface evaluation tests, Schirmer's I test, TBUT, corneal and conjunctival staining score, OSDI score, and conjunctival hyperemia score. Ocular surface imaging using LipiView and ocular surface analyzer imaging for non-invasive TBUT (NITBUT), meibomian gland, and tear imaging was performed for the OSIG treatment cohort. Study characteristics were evaluated at time of recruitment into the study (baseline visit) and at serial follow-up of months 3, 6, and 12 in OSIG treatment group and follow-up at month 6 in conventional treatment group. Treatment grading score was devised in accordance to the frequency of application of lubricants and steroids and potency of steroids. Our study of 71 eyes of 36 patients [mean age 39 ± 11.80 years] in OSIG treatment cohort group and 64 eyes of 32 patients [mean age 40 ± 11.53 years] in conventional treatment cohort group observed a significant reduction in the objective ocular surface symptom assessment parameters of OSDI scores, and dry eye severity level with improvement in clinical assessment parameters of TBUT, ocular surface staining scores, and conjunctival hyperemia grades in eyes on adjunct OSIG treatment cohort as compared to the conventional therapy cohort. The frequency of topical lubricants and steroids along with the potency of steroids used showed a decreasing trend with 45.28% noted to have become free of steroid dependence at the end of 12 months of OSIG therapy. Adjunct topical IgG therapy also enabled the shifting of 37.14% of eyes from higher to lower potency steroids by the end of 12 months of treatment with OSIG therapy. The frequency of administration of lubricants decreased in 83.33% of eyes 12 months follow-up. The success rate determined based on improvement in ocular surface evaluation was 75.76%, treatment scores improved in 74.98%, and symptoms evaluation (OSDI) was 75.76% in the OSIG therapy cohort. Topical immunoglobulin IgG 0.4% as adjunct therapy seems to have a definitive role in reducing topical steroid and lubricant dependency in moderate to severe chronic DED compared to conventional therapy.

Objectives:The use of benzalkonium chloride (BAC)-preserved medications is associated with ocular surface disease (OSD) that can negatively affect quality of life (QoL) in glaucoma patients. This study aimed to compare QoL and correlate it with OSD in glaucoma patients receiving BAC-preserved and BAC-free travoprost.Materials and Methods:A total of 110 subjects were divided into 3 groups: 40 primary open-angle glaucoma (POAG) patients using BAC-preserved travoprost, 40 POAG patients using BAC-free travoprost, and 30 age-matched controls. All patients were assessed using a single interviewer-administered format of the Ocular Surface Disease index (OSDI) and Glaucoma Quality of Life-15 (GQL-15) questionnaires.Results:Mean GQL-15 score in the BAC group was significantly higher than in the BAC-free group (24.71±7.42 vs. 17.58±3.06; p<0.05). The mean difference in GQL-15 scores between controls and the BAC-free group (1.24) was insignificant (p>0.05). There was a strong positive correlation between OSDI scores and GQL-15 scores in all the groups (r values: BAC: 0.63, BAC-free: 0.23, controls: 0.29), with higher OSDI scores (severe OSD) associated with higher GQL-15 scores (worse QoL). Cronbach’s alpha was 0.84 for GQL-15 and 0.75 for OSDI.Conclusion:BAC-preserved travoprost leads to higher OSDI scores, which correlate strongly with poor QoL scores as compared to BAC-free travoprost. The use of BAC-free formulations should be encouraged to reduce the onset or worsening of OSD and impaired QoL in glaucoma patients.

To examine the ocular surface disease in primary open-angle glaucoma (POAG) patients already on treatment versus POAG patients without treatment. A prospective cohort study was conducted on 120 eyes of 60 POAG patients: 60 treatment-naïve eyes (group I) and 60 eyes already on topical anti-glaucoma medications (AGMs) (group II). All patients had filled out the Ocular Surface Disease Index (OSDI) questionnaire and underwent a comprehensive glaucoma workup. Tear break-up time (TBUT) test, Schirmer's test (type I), corneal sensitivity, anterior segment-optical coherence tomography (AS-OCT), and corneal and conjunctival staining were done at day 1, 1 month, 3 months, 6 months, and 12 months follow-up. On presentation, TBUT, Schirmer's test, tear meniscus height (TMH), and tear meniscus depth (TMD) were significantly higher in group I compared to group II. No significant difference was noted in OSDI score, corneal sensitivity, and tear meniscus area (TMA) between the groups on presentation. Both, lissamine green and rose bengal staining, had higher grades in group II compared to group I. Worsening of ocular surface disease was noted in both groups on follow-up. OSDI score, TBUT, Schirmer's test, TMH, and TMD had better values in group I in comparison to group II on follow-up. The study has identified glaucoma patients on AGMs to be more affected by dry eye disease (DED) compared to treatment-naive glaucoma patients. We found statistically significant differences in values of TBUT, Schirmer tests, lissamine and rose bengal staining, and AS-OCT parameters at baseline and 3, 6, and 12 months follow-up. OSDI scores showed significant differences at 6 and 12 months of follow-up. We recommend consideration of evaluation and management of DED/ocular surface disease in glaucoma patients on topical AGMs, particularly multiple drugs and doses.

Purpose:The purpose of this study was to describe the prevalence and pattern of ocular surface disease (OSD) in glaucoma patients using preserved topical antiglaucoma medications in a Nigerian population.Methodology:A comparative study of patients who had used topical preserved antiglaucoma medications for 6 months or more with age- and sex-matched individuals who were not on any other form of topical eye medication was carried out using fluorescein tear breakup time (FTBUT), Schirmer I test, and ocular surface staining with fluorescein and lissamine green. The right eyes of 103 eligible patients with primary open-angle glaucoma and that of 103 age- and sex-matched individuals (controls) were included in the study.Results:The prevalence of OSD among users of preserved topical antiglaucoma medications was significantly higher than among nonusers as assessed by FTBUT (83.5% vs. 57.3%;P < 0.001), Schirmer I (30.1% vs. 17.5%; P = 0.033), and ocular surface staining (62.1% vs. 31.1%;P < 0.001). Users of preserved topical antiglaucoma medications also had worse grades of OSD evaluated by FTBUT (P = 0.001), Schirmer I (P = 0.023), and ocular surface staining (P < 0.001).Conclusion:The prevalence of subjective OSD was significantly higher among users of topical antiglaucoma medications than nonusers. Hence, preserved topical medication use is a serious concern for increased ocular surface morbidity among glaucoma patients. This calls for more attention to be paid to the consequences of OSD among glaucoma patients on topical medications.

Graves' Orbitopathy (GO) is an autoimmune disorder characterized by inflammation of orbital tissues, leading to various ocular manifestations, including ocular surface disease. This cross-sectional study aimed to assess the presence of ocular surface disease using the Ocular Surface Disease Index (OSDI) in patients with Graves' disease (GD) and moderate-to-severe active GO compared to those with GD and mild non-active GO. Additionally, we aimed to investigate the correlation between ocular surface disease and the eye features of GO. Consecutive GD patients with GO referred to the Ophthalmology and Endocrinology Units of the University Hospital of Pisa between June 2022 and February 2023 were enrolled. OSDI scores were obtained from 79 GD patients, categorized into moderate-to-severe active GO and mild non-active GO groups. OSDI scores were significantly higher in patients with moderate-to-severe active GO compared to those with mild non-active GO (P=0.0006). A cutoff value of 33 for positive tests revealed a higher frequency of pathological OSDI in moderate-to-severe active GO patients compared to mild non-active GO patients (P=0.0221; OR 3.673, CI 1.277-9.531). Within the moderate-to-severe active GO group, a significant positive correlation was found between OSDI and Clinical Activity Score (CAS) (R= 0.3867, 95% CI from 0.1403 to 0.5880; P=0.0030). Using a cutoff value of 55 (the 75th percentile of the study population), patients with CAS ≥ 3 had a significantly higher proportion of pathological OSDI compared to those with CAS <3 (P=0.0039; OR 4.075, CI 1.619-10.39). Proptosis values ≥ 22 mm and the presence of lagophthalmos were identified as significant risk factors for ocular surface disease development (P=0.0406 and P=0.0493, respectively). Our study highlights a significantly higher prevalence of ocular surface disease, as measured by OSDI, in patients with moderate-to-severe active GO compared to those with mild non-active disease. The degree of GO activity positively correlates with ocular surface involvement, and proptosis and lagophthalmos increase the risk of its occurrence. These findings emphasise the importance of assessing and managing ocular surface health in GO patients. Early identification and appropriate treatment of ocular surface disease need to be pursued to improve patient management.

Purpose: Chronic topical treatment to control intraocular pressure (IOP) is key to prevent the progression of optic nerve damage in patients with glaucoma.Despite that, this treatment may cause disturbances of the ocular surface homeostasis and tear film leading to Ocular Surface Disease (OSD).This study aimed to evaluate the prevalence of OSD in glaucoma patients under topical treatment, quantifying symptoms and objective ocular surface parameters and analyze the impact of ocular surface treatment on OSD and IOP control. Methods:Patients with primary open angle or primary angle closure glaucoma under topical treatment for at least 6 months were enrolled in the study.Patients underwent symptom screening with the ocular surface disease index (OSDI) questionnaire, assessment of objective ocular surface parameters using specific equipment, ocular surface staining and Schirmer test.A treatment for OSD with eyelid hygiene, fluormetolone acetate 0.1%, preservative-free lubricants, free-acid supplementation and oral tetracyclin derivate was started, and a second evaluation was performed after treatment for a post treatment evaluation with the same protocol. Results:In our sample (n=19), 73.68% of the patients reported severe symptoms of dry eye disease, with OSDI scores higher than 33 at baseline.Tear film instability was found in 50% of patients, while 23.53% had severe meibomian gland abnormalities.Fluorescein and lissamine green stainings were abnormal in 88.24% and 82.35% of patients, respectively.After ocular surface treatment, statistically significant improvement was found in best-corrected visual acuity (p=0.0003),OSDI score (p<0.0001),bulbar redness (p=0.0196) and fluorescein staining (p<.0001.)Mean IOP following OSD treatment reduced -1.59 mmHg from baseline in the left eye (p=0.0510). Conclusion:The frequency of OSD signs and symptoms was high in glaucoma patients under medical treatment.Short-term OSD treatment may improve ocular surface disease and IOP control, with no need to discontinue glaucoma medications.

Purpose: To establish the prevalence of ocular surface disease (OSD) in glaucoma patients using topical intraocular pressure-lowering (IOP) therapy and to compare the frequency and severity of symptoms with the control group of normal subjects.Methods: This prospective, multicenter, observational study included patients with glaucoma in four different Departments of Ophthalmology. A matched group of normal subjects served as controls. For each patient we have collected detailed family history, clinical records and calculated ocular surface disease index (OSDI) scores (0-100), based on the information obtained from OSDI questionnaires.Results: In total, we have evaluated 160 patients. Of those, 110 were glaucoma patients and 50 were normal subjects. Among 110 glaucoma treated patients 83 (75%) had OSDI scores indicating mild to severe OSD. Among 50 patients without glaucoma 15 (30%) had OSDI score indicating mostly mild to moderate OSD. The severity of symptoms correlates with the number of IOP medications used and the duration of treatment.Conclusion: This study confirms the high prevalence of OSD in patients treated for glaucoma with topical IOP medications. The adverse effect of these agents can influence the compliance and successful treatment of glaucoma patients.

PurposeChronic topical treatment for glaucoma may lead to Ocular Surface Disease (OSD). This study aimed to evaluate: (1) the prevalence of OSD in glaucoma patients under topical treatment, quantifying symptoms and objective ocular surface parameters and (2) the impact of ocular surface treatment on OSD and IOP control.MethodsPatients with primary open angle or primary angle closure glaucoma under topical treatment for at least 6 months were enrolled in the study. Patients underwent symptom screening with the ocular surface disease index (OSDI) questionnaire, assessment of objective ocular surface parameters, ocular surface staining and Schirmer test. A treatment for OSD with eyelid hygiene, fluorometholone acetate 0.1%, preservative-free lubricants, free-acid supplementation and oral tetracyclin derivate was started, and the same evaluation was performed.ResultsIn our sample (n=19), 73.68% of the patients reported severe symptoms of dry eye disease, with OSDI scores higher than 33 at baseline. Tear film instability was found in 50% of patients, while 23.53% had severe meibomian gland abnormalities. Fluorescein and lissamine green stainings were abnormal in 88.24% and 82.35% of patients, respectively. After ocular surface treatment, statistically significant improvement was found in best-corrected visual acuity (p=0.0003), OSDI score (p<0.0001), bulbar redness (p=0.0196) and fluorescein staining (p<0.0001.) Mean IOP following OSD treatment reduced −1.59 mmHg from baseline in the left eye (p=0.0510).ConclusionThe prevalence of OSD signs and symptoms was high in glaucoma patients under medical treatment. Short-term OSD treatment may improve ocular surface disease and IOP control, with no need to discontinue glaucoma medications.