Nonpreserved Artificial Tears Research Articles

Prevention and Treatment of Persistent Epithelial Defects After Common Refractive Surgery Procedures.

To discuss the prevention and treatment of persistent epithelial defects after the most common refractive surgeries-photorefractive keratectomy, laser in situ keratomileusis, or small incision lenticule extraction. PubMed was used to search the medical literature. Persistent epithelial defects are infrequent after photorefractive keratectomy, laser in situ keratomileusis, or small incision lenticule extraction. In the authors' opinion, any persistent epithelial defect present at 1 week or beyond after surgery should be treated aggressively with a properly fit bandage contact lens, lubrication with non-preserved artificial tears, and treatment of any eyelid abnormalities, including nocturnal lagophthalmos. Consideration should be given for presumptive treatment for herpes simplex virus or varicella zoster virus infection. If the persistent epithelial defect does not close within 2 weeks, then other measures should be considered, such as autologous serum drops, topical losartan, amniotic membranes, and topical human recombinant nerve growth factor to limit corneal scarring fibrosis and microbial infection. Persistent epithelial defects are among the most feared complications of refractive surgery. Timely and aggressive treatment should be instituted to close the epithelium prior to the development of scarring fibrosis and/or microbial corneal infection. [J Refract Surg. 2024;40(2):e117-e124.].

Age-Related Differences in the Clinical Patterns of Ocular Graft-Versus-Host Disease.

To evaluate age-related differences in clinical patterns of ocular graft-versus-host disease (GVHD). In this cross-sectional study, patients diagnosed with ocular GVHD were evaluated in two groups: Group I included those aged 18 years or younger and Group II included those over 18 years of age. Demographic and clinical information were recorded and compared between the groups. Forty eyes of 20 patients were included (11 patients were in Group I and 9 patients were in Group II). Follow-up was at least 6 months. All patients had burning, dryness, and foreign body sensation. Conjunctival hyperemia, cicatricial conjunctivitis, and limbal stem cell disease (LSCD) was observed more frequently in Group II. In addition to non-preserved artificial tears, cyclosporine A 0.05% (65%) and autologous/allogeneic serum eye drops (80%) were given and silicone plugs were inserted (28%). In Group I, an improvement in GVHD scoring and best corrected visual acuity was observed after 6 months of treatment (p<0.0005). In ocular GVHD, conjunctival cicatrization and limbal stem cell deficiency might be observed more often in adults. Topical cyclosporine, autologous/allogenic serum drops, and punctal plugs are helpful in moderate or more severe cases. With early diagnosis and treatment, an improvement in clinical signs and visual acuity might be observed, particularly in younger patients.

Serum drops—the last resort for topical treatment after refractive surgery and laser in situ keratomileusis-induced neuropathic epitheliopathy (LINE)

Introduction: The idea to apply blood or blood product topical treatment is not new in ophthalmology, but about 40 years ago Ralph was the first to publish this idea. The biochemical properties of serum eye drops are very similar to the water component of the tears. Serum contains several growth factors, including epidermal growth factor, transforming growth factor-β and platelet-derived growth factors, nutrients and proteins, all of which are key components for tissue regeneration. Aim: The aim of this article is to set a prospective study in order to identify and follow patients with laser in situ keratomileusis ( LASIK)-induced neuropathic epitheliopathy (LINE) and analyze the benefits of the application of 20% autologous serum drops. Materials and Methods: A total of 16 subjects (10 females and 6 males) at a mean age of 34 years (19 the youngest and 41 the oldest) were recruited prospectively. All patients were seeking second opinion as they were bothered by discomfort, visual fluctuations, chronic red eye, and pain with different characteristics. Each patient was advised to have a week of wash-out period when only non-preserved artificial tears (Hyabak 0.15%, Thea ®) were applied. Then patients were advised to apply autologous serum drops four times (during the day), and assessment was done on 4th and 8th week. The primary outcome parameters were ocular surface disease index (OSDI), tear break-up time (TBUT) and corneal staining, the secondary included visual acuity and redness. Preparation of the autologous serum drops followed the in-house methodology. Results: The patients were significantly affected by their underdiagnosed condition. Statistical analysis of the outcome parameters demonstrated that only visual acuity did not change significantly. The main outcome parameter OSDI presented highest improvement from 57 ± 12 to 12 ± 6 after 8 weeks of application of 20% autologous serum drops. Corneal staining decreased and TBUT improved in all subjects. Conclusion: Epithelial complications after LASIK are not uncommon and their recognition is the first step to long-term satisfaction of the patients with refractive procedures. After diagnosis of LINE after LASIK, especially with microkeratome, 20% autologous serum drops are an efficient long-term solution. The standard topical treatment usually takes 8 weeks to achieve good results.

A new method for treatment severe forms of dry keratoconjunctivitis (preliminary results)

The aim is to improve the treatment method of severe keratoconjunctivitis sicca (KCS) forms using designed soft contact lenses (SCL).&#x0D; Material and methods. An original SCL of silicone hydrogel material with individual optical power, consisting of a non-through depot filled with 0.05% Cyclosporin A (CyA) was designed. The therapeutic CyA saturated SCL was used in 5 patients (1 male and 4 females; 7 eyes) aged from 34 to 66 years, with severe KCS, who were constantly wearing them for 7-14 days. Patients additionally instilled hyaluronic acid containing non-preserved artificial tears up to 6 times a day. Standard ophthalmic examination, Schirmer test, tear break-up-time test, tests using vital dyes (assessed using the Oxford scale), tear osmolarity measurements (TearLab System, USA), tear pH measurement by a highly sensitive litmus test, conjunctival culture, measurement of the interpalpebral fissure width were carried out, the ocular surface disease index (OSDI) was determined. Treatment results were assessed in 1 week, 1 month, and 3 months since the SCL wear start.&#x0D; Results. The use of therapeutic CyA saturated SCL allows to achieve complete corneal epithelization, and helps to reduce inflammation within the time from 1 week up to 1 month, significantly reducing the treatment timeframe of severe forms of KSC in comparison to standard therapy.&#x0D; Conclusion.The developed treatment method for severe forms of the KCS consists in using specifically designed therapeutic SCL which provides an even CyA 0.05% release on the ocular surface, while instilling non-preserved artificial tears. Preliminary results show a high efficacy of this method in terms of reducing corneal epithelization time up to 1 week-1 month and resolving inflammation on the ocular surface.

Ocular surface diseases and corneal refractive surgery.

The purpose of this article is to provide an overview and update on recent literature regarding ocular surface disease and corneal refractive surgery. Studies involving ocular surface disease and/or keratorefractive (corneal) surgery published found on the Medline database were included in the report. Studies focused on mechanisms of refractive surgery induced dry eye disease, surgical options, including modification of technique, to prevent dry eye, and postoperative dry eye prevention and management by way of both established and novel therapies. By understanding the mechanisms of postoperative dry eye as well as patient risk factors for dry eye, patient satisfaction and surgical outcomes can be maximized. Patients identified as having an increased risk for postoperative dry eye may benefit from surgical techniques such as small-incision lenticule extraction (SMILE) and femtosecond laser-assisted in-situ keratomileusis (LASIK). Employing well known therapies such as preserved and nonpreserved artificial tears, nutritional supplements, topical cyclosporins, punctal plugs and autologus serum as well as novel therapies such as insulin-like growth factor 1, neuropeptides and acupuncture could provide improve outcomes and, if started early, could allow more patients to be candidates for corneal refractive surgery.

OCT Assessment of Tear Meniscus After Punctal Occlusion in Dry Eye Disease

To evaluate the tear meniscus changes after punctal occlusion in dry eye patients using Visante optical coherence tomography (OCT) in a prospective controlled study. Thirty eyes of 15 symptomatic dry eye patients not responding to non-preserved artificial tears received additional upper and lower punctal occlusion with silicone plugs, and 30 eyes of 15 age- and sex-matched dry eye control patients received only non-preserved artificial tears treatment for 1 month. All subjects underwent tear meniscus height (TMH) measurements with Visante OCT. All study participants also underwent slitmicroscopy graticule scale TMH measurement, strip meniscometry testing, tear film break-up time measurement, ocular surface vital staining with fluorescein and Rose Bengal dyes, and the Schirmer-1 test. Both groups, dry eye and control group patients, were examined before and after 1-month treatment. Wilcoxon-matched pair test was performed. The study was conducted in compliance with the Tenets of the Declaration of Helsinki. TMH measurements by OCT and slitlamp graticule scale significantly improved after punctal occlusion (p < 0.001) and remain unchanged in the dry eye control patients. Similarly, strip meniscometry scores, mean tear stability values, Rose Bengal, and fluorescein staining scores showed significant improvement after punctal occlusion (p < 0.05). Schirmer-1 test values tended to be higher after 1 month of treatment in both groups without any statistical significance (p > 0.05). OCT TMH measurement appears to be effective in monitoring tear meniscus changes after punctal occlusion. OCT can be a valuable non-invasive and quick clinical tool for evaluation of treatment responses in dry eye patients.

The evaluation of the treatment response in obstructive meibomian gland disease by in vivo laser confocal microscopy

To evaluate the status of periglandular inflammation, ocular surface and tear function alterations in patients with obstructive meibomian gland disease (OMGD) by in vivo confocal microscopy before and after anti-inflammatory treatment, and to compare the results with patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops without anti-inflammatory agents. Thirty-two eyes of 16 OMGD patients receiving anti-inflammatory treatment (treatment group) and 22 eyes of 11 OMGD patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops (control group) were recruited in this prospective study. All subjects underwent slit-lamp examinations, tear film break-up time (BUT) measurements, fluorescein and Rose-Bengal stainings, Schirmer test capital I, Ukrainian without anesthesia, transillumination of the lids (meibography), and in vivo laser confocal microscopy of the lids (HRTII-RCM). The mean BUT, fluorescein staining scores, and inflammatory cell densities observed by in vivo confocal microscopy improved significantly in the group receiving anti-inflammatory treatment (p < 0.05), whereas no significant alterations of these parameters were observed in the group not receiving anti-inflammatory agents (p > 0.05). In vivo confocal microscopy was able to effectively demonstrate the treatment responses in patients with OMGD. Inflammatory cell density calculation seems to be a promising new parameter of in vivo confocal microscopy in the evaluation of treatment responses.

Long-term Resolution of Chronic Dry Eye Symptoms and Signs after Topical Cyclosporine Treatment

To report the resolution of symptoms and signs of chronic dry eye for at least 1 year after completion of a minimum 6-month course of topical 0.05% cyclosporine in a subgroup of patients from 2 practices. Retrospective case series. Eight patients who had had chronic dry eye disease for 3 to 20 years were treated with topical cyclosporine for 6 to 72 months, and then remained free of symptoms or signs of disease for at least 1 year (range, 16-29 months; mean, 21 months) after stopping treatment. Treatment with topical 0.05% cyclosporine with or without topical corticosteroids twice a day along with nonpreserved artificial tears. Tests performed were patient history, slit-lamp examination, rose bengal and fluorescein staining of the ocular surface, tear breakup time, and Schirmer's test with anesthesia. Resolution of all symptoms and signs of dry eye disease after a minimum 6-month course of topical 0.05% cyclosporine. Eight patients, including approximately 4% of the total patients with chronic dry eye treated with 0.05% cyclosporine in one author's practice, were free of signs or symptoms of dry eye disease a minimum of 1 year after completing a 6- to 72-month course of therapy. There were no parameters noted that distinguished these patients from others who required maintenance topical cyclosporine or who did not appear to respond to topical cyclosporine. Topical cyclosporine treatment appears to be associated with a cure of symptoms and signs in a subgroup of chronic dry eye patients. In such patients, presumably there is effective elimination of inflammatory processes underlying chronic dry eye disease. Such patients should be monitored long term because a return of disease may be noted. These results suggest that topical cyclosporine treatment halts progression of chronic dry eye in some patients.

A case report and review of filamentary keratitis

Filamentary keratitis is most often a chronic corneal condition, characterized by filaments attached at one or both ends to the cornea. Patients often experience foreign body sensation, grittiness, discomfort, photophobia, blepharospasm, and increased blinking. Filamentary keratitis is commonly the result of aqueous deficient dry eye syndrome. Management options include lubrication, punctal occlusion, removal of filaments, hypertonic saline, mucolytic agents, anti-inflammatory agents, and therapeutic contact lenses. A 58-year-old man came to us with acute symptoms of pain, photophobia, and redness x 2 days 0.S. The diagnosis of filamentary keratitis was made based on the clinical findings of positively staining mucus strands attached to the superior cornea. The patient was also found to have dry eye, blepharitis, and floppy eyelid syndrome. Numerous treatment regimens were implemented, including lubrication with non-preserved artificial tears, lubricating ointment, and topical steroids. The patient's condition was finally best managed with silicone plug punctal occlusion and therapeutic contact lenses. Filamentary keratitis can be a recurrent and incapacitating condition that may prove difficult to manage.

Ocular surface management of photorefractive keratectomy and laser in situ keratomileusis

THE AUTHORS PERFORMED A RETROSPECTIVE ANALYSIS of the effects photorefractive keratectomy (PRK) and in-situ keratomileusis (LASIK) with and without ocular surface management on the incidence of dry eye symptoms and goblet cell density. Ocular surface management involved the routine use of non-preserved artificial tears and other lubricants before, during, and after surgery. Lid hygiene procedures, topical anti-inflammatory agents, and punctual plugs were used on indication. Study groups included untreated controls (n = 53), PKP without ocular surface management (n = 51), LASIK without ocular surface management (n = 56), and LASIK with ocular surface management (n = 140). Assessments were conducted before and up to 12 months after surgery. Initially, the incidence of dry eye symptoms was significantly higher in the PRK group than in both LASIK groups. At 12 months, the incidence of dry eye symptoms were less in the PRK group than in both LASIK groups, although this difference was not statistically significant. Compared to the untreated control group, both PRK and LASIK caused a highly significant overall reduction in goblet cell density. Significant relationships between the incidence of dry eye symptoms and goblet cell density were found consistently in each group. Compared to PRK, LASIK without ocular surface management resulted in significantly lower goblet cell density overall at 1 to 3 months (P = 0.003) and 9 to 12 months (P = 0.02). Ocular surface management minimized the LASIK-induced decrease in goblet cell density compared to the LASIK group without ocular surface management. At each time point, goblet cell density was significantly higher in the LASIK with ocular surface management. The authors conclude that ocular surface management reduces the negative impact of goblet cell loss and dry eye symptoms after LASIK.—Michael D. Wagoner

Conservative treatment of meibomian gland dysfunction.

To evaluate the effectiveness of lid hygiene and preservative-free artificial tears for the treatment of meibomian gland dysfunction (MGD) during a 6-week period. Suitable patients with MGD were educated about their disease and instructed to begin a regimen of lid hygiene, which included the application of a heated saline solution and the use of nonpreserved artificial tears. Baseline measurements obtained at the time of enrollment included basic tear secretion test, tear breakup time, a questionnaire grading MGD symptoms (i.e., burning, irritation, itching, sharp pains, foreign body sensation, and hazy vision), and lid margin slitlamp photographs. All measurements except for basic tear secretion were repeated at the 6-week follow-up visit. Photographs were unlabeled, and two cornea specialists graded them in a masked fashion for the presence of lid erythema, irregularity, thickness, meibomian gland capping, and telangiectasis. Thirty-seven patients with a clinical diagnosis of MGD were enrolled, and 26 patients (70%) completed the study. Initial measurement of basic tear secretion averaged 17 mm and was more than 10 mm in 81% of eyes. The tear breakup time was prolonged by an average of 3.4 seconds; in 30% of cases, it was normalized to 10 seconds or more. Symptoms improved in 88% of cases; among those, symptoms were graded mild or less in 83%, and none in 39%. Photographs before and after treatment were not significantly different. In this noncontrolled case-cohort study of selected patients with MGD, lid hygiene and preservative-free artificial tears significantly improved tear breakup time and relieved symptoms of the condition.

The survival of herpes simplex virus in multidose office ophthalmic solutions

PURPOSE: To determine the survival of herpes simplex virus type 1 (HSV-1) in several multidose ophthalmic solutions. METHODS: In three separate trials, 10 aliquots of 5 ml each of three common multidose topical ophthalmic solutions, sodium fluorescein, proparacaine, and nonpreserved artificial tears, were inoculated with 10 5, 10 4, and 10 3 pfu per ml of HSV-1. All samples were titered on A549 cells at various time points for surviving HSV-1. RESULTS: Herpes simplex virus type 1 was not recovered from the fluorescein and proparacaine solutions at 1 hour or any time thereafter, regardless of inoculation titer. Herpes simplex virus type 1 was recovered from the artificial tears up to 7 days. CONCLUSION: Unlike adenovirus, HSV-1 does not survive in preserved fluorescein and proparacaine multidose solutions; therefore, office transmission is highly unlikely.

Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjögren syndrome

Objective To review the efficacy and side effects of topical nonpreserved corticosteroid therapy for treatment of severe keratoconjunctivitis associated with Sjögren syndrome. Design Retrospective, noncomparative case series. Participants Twenty-one patients with Sjögren syndrome-associated keratoconjunctivitis sicca and annoying ocular irritation. Intervention Treatment with topical nonpreserved methylprednisolone sodium succinate. Main outcome measures Symptom severity, frequency of instillation of artificial tears, corneal fluorescein staining scores, resolution of filamentary keratitis, steroid-related side effects. Results Before starting methylprednisolone therapy, all patients were experiencing moderate-to-severe eye irritation despite prior punctal occlusion in most cases and frequent use of nonpreserved artificial tears by all. After 2 weeks of topical application, three to four times per day, moderate (43%) or complete (57%) relief of irritation symptoms was experienced by all patients and no complications were observed. An average decrease in corneal fluorescein scores of 2.6 ± 0.5 points (on a 12-point scale) was observed, and filamentary keratitis resolved in all ten eyes with this condition. Therapy was stopped after 2 weeks in eight patients, and six of these patients reported that their symptoms remained at a tolerable level for weeks to months. Lower dose steroid therapy was continued in the remaining patients, whose symptoms worsened after attempted weaning. Complications of corticosteroid therapy in patients receiving prolonged therapy included increased intraocular pressure in one patient at 3 months, worsening of pre-existing posterior subcapsular cataracts in one patient at 6 months, and formation of posterior subcapsular cataracts in another patient at 6 months. Conclusions These findings indicate that topical nonpreserved methylprednisolone is an effective treatment option for patients suffering from severe keratoconjunctivitis sicca who continue to experience bothersome eye irritation despite maximum aqueous enhancement therapies. They also suggest that inflammation is a key pathogenic factor in this condition. Careful monitoring is essential in dry eye patients treated with corticosteroids for more than 2 weeks because steroid-related complications (increased intraocular pressure and cataract formation) were observed after several months of therapy in this series. Because of the chronic nature of this disease and the likelihood of patients developing steroid-related complications with their long-term use, topical nonpreserved methylprednisolone therapy appears to be most appropriate for short-term “pulse” treatment of exacerbations of keratoconjunctivitis sicca.

Advances in the diagnosis and management of keratoconjunctivitis sicca.

Keratoconjunctivitis sicca is a common ocular surface disease that develops in patients with aqueous tear deficiency. Recent advances have been made in diagnosis, pathogenesis, and therapy of this condition. Advances in diagnosis include improved understanding of the specificity of the tests used for diagnosis, elucidation of the mechanism of the ocular surface rose bengal and fluorescein staining that occurs in this condition, and the expanded use of impression cytology. Advances in pathogenesis include the concept that keratoconjunctivitis sicca is a condition of abnormal growth and differentiation and immune activation of the ocular surface epithelium. These findings indicate that keratoconjunctivitis sicca may represent a chronic wound-healing response to a poorly lubricated and inflamed ocular surface. Advances in therapy include improved nonpreserved artificial tears and therapies targeted at decreasing ocular surface inflammation.