Ocular Surface Discomfort Research Articles

Topical Review: Effects of Contact Lens Wear on Corneal, Conjunctival, and Lid Margin Sensitivity.

Contemporary soft contact lenses do not affect mechanical sensitivity of the cornea, whereas conjunctival sensitivity is increased compared with nonwearers. Orthokeratology lens wear, however, reduces corneal sensitivity. The effects of contact lenses on lid margin sensitivity are unclear, and the link between ocular surface sensitivity and discomfort requires further exploration.Although up to 50% of contact lens wearers experience discomfort with varying severity, impact, and frequency, the relationship between ocular surface sensitivity and ocular surface discomfort experienced during contact lens wear is unclear. The purpose of this review is to examine and summarize the current evidence for the impact of both historical and contemporary contact lens wear on ocular surface sensitivity, the etiology of changes in ocular surface sensitivity, contact lens wear-related factors associated with changes in ocular surface sensitivity, and the relationship between sensitivity and discomfort. Despite minimal effects on mechanical corneal sensitivity with contemporary soft contact lens wear, orthokeratology reduces corneal sensitivity through pressure-related effects. This review addresses the relevance of conjunctival and potentially lid margin sensitivity in tolerance and discomfort with contemporary lens wear and the impact of instrument and stimulus characteristics. Less invasive techniques particularly for lid margin sensitivity measurements are required. Given the potential interactions between a contact lens and the varied types of ocular surface nociceptors, instruments that allow for exploration of cold and chemical sensitivity particularly may better allow the effects of lens wear to be elucidated compared with those that explore high-threshold mechanical sensitivity alone. A better understanding of the relationships between lens wear and ocular surface sensitivity may result in improved management of contact lens discomfort.

Efficacy of carbomer sodium hyaluronate trehalose vs hyaluronic acid to improve tear film instability and ocular surface discomfort after cataract surgery.

PurposeTo evaluate the effects of carbomer sodium hyaluronate trehalose (CHT) and sodium hyaluronate eye drops on tear film stability and ocular discomfort after cataract surgery.SettingSanta Maria della Misericordia Hospital, Rovigo, Italy.DesignProspective randomized case-control study.Patients and methodsThis study enrolled sixty patients scheduled for unilateral cataract surgery. After phacoemulsification, subjects received carbomer sodium hyaluronate trehalose (trehalose group) or sodium hyaluronate tears (HG group) substitute and were assessed through objective (break up time, corneal and conjunctival staining) and subjective (OSDI questionnaire) clinical evaluations after a two times a day topical administration. Outcome measures were collected preoperatively (baseline), one week (day 7) and 1 month (day 30) after surgery. Finally, each patient was asked to give his personal treatment satisfaction score.ResultsTrehalose group showed a steeper break up time (BUT) increase compared to patient treated with hyaluronic acid (P<0.001). OSDI questionnaire presented a opposite trend, trehalose patients evidenced a significantly major improvement (P<0.001), and in seven days mean values reduced by more than three times. Fluorescein staining reduction was documented with both treatments, although there was no statistically significant difference between groups. Finally CHT resulted in a significantly greater global satisfaction score (P<0.001).ConclusionsCHT was effective and well tolerated in reducing dry eye disease symptoms and improving the clinical outcome after cataract surgery. On some parameters (BUT, OSDI), this new formulation was more effective than commonly used sodium hyaluronate in treating ocular irritation and tear film alterations.

Efficacy of a Topical Heparan Sulfate Mimetic Polymer on Ocular Surface Discomfort in Patients with Cogan's Epithelial Basement Membrane Dystrophy

Purpose: Treatment of persistent ocular discomfort in patients with Cogan's epithelial basement membrane dystrophy (EBMD) is a challenge for ophthalmologists. This study aimed to determine the efficacy of a topical heparan sulfate mimetic polymer (HSMP) in reducing ocular discomfort in EBMD patients. Methods: This retrospective, noninterventional study included 22 consecutive patients in 3 tertiary ophthalmological units with spontaneous, recurrent, acute ocular pain, resistant to various topical lubricants. After EBMD diagnosis, HSMP treatment was initiated while lubricating eye drops were continued. The main study outcome was the change in ocular discomfort assessed using the ocular surface disease index (OSDI) from initiation of treatment to last follow-up visit. Results: The mean OSDI decreased from 46.7 ± 22.3 to 31.6 ± 17.4 (P < 0.001) at first visit and 32.5 ± 17.9 (P < 0.01) at last visit. The rate of patients with severe ocular surface disease (OSDI >33) decreased from 68.2% to 36.4% at first visit and 42.9% at last visit. After a median follow-up of 8.5 months, 7 (31.8%) patients discontinued the HSMP treatment due to a marked improvement in ocular surface comfort and no recurrence of ocular pain, 5 (22.7%) due to lack of efficacy, and 1 (4.5%) due to an ocular adverse event (not treatment related). Eight patients continued treatment after the last visit and 1 patient was lost to follow-up. Globally, HSMP prevented acute painful episodes in 11 (61.1%) of 18 patients followed for ∼4 months. Conclusions: Topical HSMP may be an option for alleviating ocular discomfort in patients with EBMD resistant to standard symptomatic treatments.

Dysregulated Tear Fluid Nociception-Associated Factors, Corneal Dendritic Cell Density, and Vitamin D Levels in Evaporative Dry Eye.

The purpose of this study was to study the status and association among tear-soluble factors, corneal dendritic cell density, vitamin D, and signs and symptoms in dry eye disease (DED). A total of 33 control subjects and 47 evaporative dry eye patients were included in the study. DED diagnosis and classification was based on the 2017 Report of the Tear Film & Ocular Surface Society International Dry Eye Workshop (TFOS DEWS II). DED workup, including tear film break-up time (TBUT), Schirmer's test I (STI), corneal and conjunctival staining, ocular surface disease index (OSDI) scoring, and in vivo confocal microscopy (to assess corneal dendritic cell density [cDCD] and subbasal nerve plexus [SBNP] features) was performed in the study subjects. Tear fluid using Schirmer's strip and serum were collected from the subjects. Multiplex ELISA or single analyte ELISA was performed to measure 34 tear-soluble factors levels including vitamin D. Significantly higher OSDI discomfort score, lower TBUT, and lower STI were observed in DED patients. cDCD was significantly higher in DED patients. No significant difference was observed in SBNP features. Tear fluid IL-1β, IL-17A, MMP9, MMP10, MMP9/TIMP ratio, and VEGF-B were significantly higher in DED patients. Significantly lower tear fluid IL-2, IP-10, NPY, VEGF-A, and vitamin D was observed in DED patients. These dysregulated tear factors showed significant associations with DED signs and symptoms. Altered tear fluid soluble factors with potential to modulate nociception exhibited a distinct association with ocular surface discomfort status, TBUT, STI, and cDCD. This implies a functional relationship between the various tear-soluble factors and dry eye pathogenesis, indicating new molecular targets for designing targeted therapies.

Association of Sulfur Mustard-induced Ocular Problems with Serum and Blood Biochemical Parameters Changes

Many biochemical features of sulfur mustard (SM) intoxication have remained unknown. So far, the direct association between biochemical parameter changes and ocular problems in patients exposed to SM is not evaluated. The current study aimed at evaluating the associations between the ocular findings in patients with SM intoxication and the changes of serum and blood biochemical parameters. In the current study, 372 patients exposed to SM and 128 matched controls were compared concerning the association between their ocular problems and biochemical parameters. Ocular problems include photophobia, ocular surface discomfort (OSD), etc. Biochemical parameters include uric acid, creatinine (Cr), hematocrit (HCT), total, direct and indirect bilirubin, high-density lipoproteins (HDL), alanine aminotransferase (ALT), calcium (Ca), fasting blood sugar (FBS), mean corpuscular hemoglobin concentration (MCHC), etc. The SM-exposed group with photophobia, OSD, tearing, blurred vision, abnormal tear status, and slit-lamp findings had significantly higher mean serum and blood levels of uric acid, Cr, HCT, and total and indirect bilirubin than the controls. The SM-exposed group with photophobia, tearing, ocular pain, blurred vision, bulbar conjunctival and limbal abnormalities had significantly higher mean serum and blood levels of HDL, ALT, Ca, FBS, MCHC, and HDL, indirect and total bilirubin, compared to the control group. The association of photophobia with uric acid, OSD and tearing with Cr, photophobia with HDL, ocular pain with Ca, and blurred vision with FBS may be explained for their known ocular effects in the SM-exposed subjects. SM-induced biochemical changes may intensify the ocular problems induced by the direct effects of SM.

The Association between Ocular Problems and Serum Testosterone, Prolactin and Thyroglobulin Concentrations in Delayed Phase of Sulfur Mustard Exposure

Aside from direct toxic effects, Sulfur Mustard (SM) induced serum hormone abnormalities may aggravate ocular complaints, including Ocular Surface Discomfort (OSD) (burning, itching, and redness), dry eye sensation, photophobia, blurred vision, foreign body sensation, and pain. The aim of the current study was to investigate the possible association of ocular complaints with serum hormone concentrations in chronic phase of Sulfur Mustard (SM) exposure. As a part of Sardasht Iran Cohort Study (SICS), 372 SM-exposed patients and 128 non-exposed participants were enrolled. Ocular complaints and ocular surface biomicroscopic conditions and serum hormones were compared. The exposed with tearing group had significantly higher mean serum levels of testosterone and prolactin (ng/mL) than controls (5.75 vs. 4.75, P=0.031; 11.71 vs. 8.42, P=0.009). The exposed with OSD group had significantly higher mean serum levels of prolactin than controls (12.48 vs. 6.90, P=0.002). The exposed with photophobia group had significantly higher mean serum levels of testosterone than the matched exposed (6.25 vs. 5.65, P=0.013). The exposed with blurred vision group had significantly higher mean serum levels of Thyroglobulin (Tg) (ng/mL) than the matched exposed (65.73 vs. 32.6, P=0.003). Higher mean serum levels of testosterone (in exposed with tearing and photophobia) and prolactin (in exposed with tearing and OSD) may play protective roles against SM effects. Higher mean serum levels of Tg may deteriorate the tear film integrity and optical surface, which causes blurred vision. In the chronic phase of SM toxicity, some ocular surface problems are associated with alterations in the serum concentrations of testosterone, prolactin, and Tg.

Discomfort self‐perception in contact lens wearers

PurposeChronic use of contact lenses (CLs) disturb ocular surface, leading to loss of corneal epithelium integrity and ocular discomfort. In many patients, there is no correlation between the severity of ocular surface disturbances and the perceived discomfort. In the present work, we analyzed the correlation between discomfort self‐perception and ocular surface disease index in contact lens wearers.MethodsForty contact lens wearers of both sexes, 18‐25 years old participated voluntarily in the study. An ad‐hoc questionnaire (Likert scale survey type) was used to score the frequency and intensity of ocular surface discomfort and dryness sensation. Ocular Surface Disease Index (OSDI) adapted for Spanish speakers was also administered. An equivalent group of age and sex‐matched volunteers with similar refractive errors that never wore CLs served as control.ResultsSignificant differences were found between CL and eyeglasses wearers in medium‐high intensity discomfort sensations (72.5% vs 32.5%, CL vs spectacle wearers, p=0.003), eye dryness sensation (87.5% vs 57.5%, p= 0.001), presence discomfort sensation during the day (92.5% vs 77.5%, p=0.011) and frequency of watering eye sensation (90% vs 27.5%, p=0.001). There were no significant differences in the frequency of headache nor in the need to use artificial tears. Surprisingly, no differences were found in OSDI questionnaire between CL and eyeglasses wearers.ConclusionsContact lens wearers most frequently perceive eye surface alterations than eyeglass wearers, although there are no significant differences in OSDI questionnaire.(Supported by SAF2014‐54518‐C3‐1‐R, MINECO, Spain, and ERDF, European Commission)

Validation of Farsi Translation of the Ocular Surface Disease Index.

Purpose:To develop and validate a Farsi version of Ocular Surface Disease Index (OSDI) for the Iranian population.Methods:This study was a translation and cross-cultural adaptation and validation of Farsi version of OSDI. Four bilingual (English-Persian) individual including three physicians and one native English teacher were asked to translate the original English OSDI questionnaire in Farsi. Following back and forth translation, integration and pilot check, the translation team came to consensus on translation. Consecutive patients visited in ophthalmology clinic, underwent comprehensive general ophthalmology exam and specific assessments for dry eye including non-anesthetic Schirmer's test, fluorescein tear break-up time, Fluorescein and Rose Bengal staining and Farsi OSDI (F-OSDI). F-OSDI was again rechecked within 2-7 days after the examination.Results:Forty-four participants were enrolled into study. Thirty-two (72.7%) were male and 12 (27.3%) female. Mean age of participants was 45.5 (SD = ±15.97, range = 18-80) years. Twenty five percent were less than 31 years old and 10% percent older than 65. The cronbach's alpha for the questionnaire was 0.807. Questions number 7, 8 showed excellent, and question12 showed good internal consistency, respectively. There was a significant correlation between all pre measures and post assessments.Conclusion:The obtained F-OSDI showed acceptable internal consistency and test-retest reliability. This F-OSDI could be used for assessment of dry eye, ocular surface discomfort and quality of life in Iranian and Farsi speaking populations.

In vivo thickness dynamics measurement of tear film lipid and aqueous layers with optical coherence tomography and maximum-likelihood estimation.

Dry eye disease (DED) is a common ophthalmic condition that is characterized by tear film instability and leads to ocular surface discomfort and visual disturbance. Advancements in the understanding and management of this condition have been limited by our ability to study the tear film secondary to its thin structure and dynamic nature. Here, we report a technique to simultaneously estimate the thickness of both the lipid and aqueous layers of the tear film in vivo using optical coherence tomography and maximum-likelihood estimation. After a blink, the lipid layer was rapidly thickened at an average rate of 10 nm/s over the first 2.5 s before stabilizing, whereas the aqueous layer continued thinning at an average rate of 0.29 μm/s of the 10 s blink cycle. Further development of this tear film imaging technique may allow for the elucidation of events that trigger tear film instability in DED.

Prevalence, risk factors, and morbidity of eye lid laxity in a veteran population.

The aim of this study was to study prevalence, risk factors, and morbidity of eyelid laxity in a veteran population. This prospective cross-sectional study with a retrospective chart review included 150 subjects evaluated from either an outpatient eye clinic or a geriatric clinic at the Miami Veterans Affairs Hospital from June through August 2013. Clinical data were gathered from a questionnaire and a computerized medical record system including demographics, medical history, and ocular irritation history. Upper and lower eyelid laxity was clinically graded. Main outcome measures were prevalence of eyelid laxity, risk factors for its presence, and its correlation to ocular surface symptoms. Fifty-four percent of participants (n = 81) had laxity (grade 1 or higher) in either upper and/or lower eyelids. Risk factors for eyelid laxity in our population included older age, higher body mass index, and a diagnosis of sleep apnea. Patients with any eyelid laxity (grade 1 or more in any eyelid) had a 2.23-fold risk of severe ocular surface symptoms (score of 12 or higher on the dry eye questionnaire 5) compared with those without laxity (95% confidence interval, 1.15-4.31; P = 0.017), and this was primarily driven by the presence of upper eyelid laxity. We found high prevalence of eyelid laxity in our population, and its presence was associated with significant ocular surface morbidity. This study reinforces the need to incorporate dynamic eyelid testing into ophthalmic examination in patients with ocular surface discomfort.

Efficacy of preservative-free tafluprost in patients with normal-tension glaucoma previously treated with latanoprost.

Dear editor We read with interest the article entitled “Effects of tafluprost treatment for 3 years in patients with normal-tension glaucoma” by Inoue et al.1 In this study, the authors reported the efficacy of tafluprost in naive patients with normal-tension glaucoma (NTG) over 3 years of follow-up. The intraocular pressure (IOP)-lowering efficacy of tafluprost in NTG has been recently reported by Mizoguchi et al2 and Nakano et al.3 Whereas tafluprost is available in Europe in a preservative-free formulation, the three aforementioned studies1–3 were all carried out in Japan, where tafluprost is on the market as a benzalkonium chloride (BAK)-containing formulation. Recent literature reported BAK-related ocular surface inflammation and epithelial damage,4 which led to the development of preservative-free antiglaucoma drugs. The cytotoxic effect of BAK on conjunctival and corneal epithelium has been claimed to increase ocular penetration of topical drug, enhancing the therapeutic effect.5 As the presence of preservative may play a role in the IOP-lowering effect, we believe it is of interest to report the efficacy of BAK-free formulations in NTG. In a previous study by our group, BAK-free tafluprost showed a comparable efficacy to other prostaglandin analogs, with a safe profile in patients with primary open-angle glaucoma.6 In this letter, we want to report our experience with preservative-free tafluprost in patients with NTG. Herein, we present a retrospective study on 58 eyes of 58 patients (mean age 65.8±9.2 years, range 43–91 years) with NTG previously treated with BAK-preserved latanoprost who were switched to unpreserved tafluprost for ocular surface discomfort. The study was carried out with approval from the Institutional Ethics Committee (San Giuseppe Hospital, MultiMedica) and adhered to the tenets of the Declaration of Helsinki. To be included, patients had to have unilateral or bilateral NTG. Diagnosis of NTG was made on the basis of optic-disk abnormalities and visual-field defects judged by a trained glaucoma specialist to be characteristic of glaucoma with IOP <21 mmHg at any time points of the diurnal IOP curve (8 am, 11 am, 2 pm, 5 pm). All patients were followed in our hospital (San Giuseppe Hospital) from January 2011 to December 2013. Inclusion criteria were: at least 3 months of treatment with BAK-preserved latanoprost followed by at least 3 months of treatment with unpreserved tafluprost; switch to tafluprost due to ocular discomfort; and availability of data from three diurnal IOP curves (untreated, treated with latanoprost, and after switch to tafluprost). Both latanoprost and tafluprost significantly reduced the diurnal mean IOP compared to baseline (12.7±1.7 mmHg versus 14.9±1.9 mmHg, −15%, P<0.001 and 12.2±1.8 mmHg versus 14.9±1.9 mmHg, −18%, P<0.001, respectively) (Figure 1). Conjunctival hyperemia was reported in 17% and 8% of patients and fluorescein corneal staining in 6% and 2% of patients receiving latanoprost and tafluprost, respectively. Figure 1 Intraocular pressure at baseline, with latanoprost, and after switch from latanoprost to tafluprost. The retrospective nature of this study, the absence of a wash-out period, and the short follow-up are all limitations of this report and we are aware that our results need to be confirmed by powered, prospective, randomized clinical trials. However, to the best of our knowledge, this is the first report on the efficacy of BAK-free tafluprost in NTG. In our study, the percentage IOP reduction from untreated baseline for both latanoprost (15%) and tafluprost (18%) was similar to that reported in other studies investigating the efficacy of prostaglandin analogs in NTG and ranging from 16%7 to 19%.8 This study suggests the effectiveness of preservative-free tafluprost in NTG, showing results comparable to those obtained in Japanese patients1–3 using a BAK-preserved formulation.

Dry eye disease in French elderly subjects: the Alienor Study

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).

Evaluation of Ocular Surface Disease in Patients with Glaucoma

To evaluate the subjective and objective measures of ocular surface disease in patients with glaucoma. Cross-sectional study. Sixty-four glaucoma subjects with bilateral visual field (VF) loss and 59 glaucoma suspects with normal VFs. Consecutive patients were recruited prospectively from the Wilmer Eye Institute Glaucoma Clinic. Tear film breakup time (TBUT), corneal staining score (0-15), and Schirmer's test results were included as objective metrics, whereas the Ocular Surface Disease Index (OSDI) questionnaire was administered to assess symptoms. Total OSDI score, vision-related subscore (derived from questions about vision and task performance), and discomfort-related subscore (derived from questions about ocular surface discomfort) were calculated for each subject. Seventy-five percent (48/64) of glaucoma subjects and 41% (24/59) of glaucoma suspects were receiving topical medications. The corneal staining grade was greater in glaucoma subjects than in glaucoma suspects (6.4 vs. 4.1; P<0.001), but groups did not differ with regard to TBUT or Schirmer's results (P>0.20 for both). Multivariate regression models showed that topical glaucoma therapy burden was associated with a significantly higher total corneal staining grade (β, +0.9 for each additional glaucoma drop; 95% confidence interval [CI], 0.5-1.3; P<0.001), but not with TBUT or Schirmer's results (P>0.20 for both). Glaucoma subjects had significantly higher total OSDI scores than glaucoma suspects (16.7 vs. 7.9; P<0.001). This largely was the result of higher vision-related subscores in the glaucoma group (11.1 vs. 3.3; P<0.001). Ocular discomfort-related subscores, however, were similar in both groups (5.7 vs. 4.6; P = 0.30). In multivariate analyses, each 5-decibel decrement in better-eye VF mean deviation was associated with a 4.7-point increase in total OSDI score (95% CI, 1.9-7.5; P = 0.001) and a 3.7-point increase in the vision-related subscore (95% CI, 1.7-5.6; P<0.001) but did not predict a higher discomfort-related subscore (β, 1.1 point; P = 0.07). Topical glaucoma therapy burden was not associated with higher total OSDI score or vision- or discomfort-related subscore (P>0.20 for all). Glaucoma is associated with significant ocular surface disease, and topical glaucoma therapy burden seems predictive of corneal staining severity. However, OSDI is a poor metric for capturing ocular surface disease in glaucoma because symptoms seem to be related largely to VF loss.

Peripheral Hypertrophic Subepithelial Corneal Degeneration: Nomenclature, Phenotypes, and Long-Term Outcomes

To describe the long-term outcomes of peripheral hypertrophic subepithelial corneal degeneration. Retrospective case series. Twenty-two patients under the care of the External Disease Service, Moorfields Eye Hospital. All patients matching clinical diagnostic criteria were included. Symptomatic patients were managed either conservatively or were offered superficial keratectomy in progressive cases where symptom control was inadequate. All excised tissue was examined histologically. Clinical phenotype, symptoms, recurrence rate after surgery, and histopathologic results. Twenty-two white patients (20 women and 2 men; age range, 27-88 years; median age, 42 years) had peripheral, usually bilateral (20/22 [91%]), elevated circumferential peripheral subepithelial corneal opacities and adjacent abnormal limbal vasculature, with or without pseudopterygia in 9 patients (41%), among whom 7 (32%) patients had bilateral disease. Apart from the abnormal vasculature, there were no signs of chronic ocular surface inflammation. Symptoms were ocular surface discomfort in 10 patients (45%), reduced vision in 4 patients (18%), and both of these in 5 patients (23%). Three patients (14%) were asymptomatic. There was no treatment in 6 patients (27%), topical lubricants in 8 patients (36%), spectacles in 1 patient (5%), and superficial keratectomy in 7 patients (32%; 5 bilateral), which was repeated for incomplete primary excision in 1 eye of 2 patients (9%) and for a bilateral recurrence in 1 patient (5%). Median follow-up after excision was 5 years (range, 1-11 years). Histopathologic changes were similar to those observed in pterygia (vascular component) and Salzmann's nodular degeneration (corneal component). Peripheral hypertrophic subepithelial corneal degeneration is an uncommon, usually bilateral, idiopathic disorder, occurring mostly in white women with a distinct phenotype. The condition was first described in 2003. Further cases among some patients have been described in more recent case series of Salzmann's nodular degeneration and diffuse keratoconjunctival proliferation, as well as in the previously described familial pterygoid corneal degeneration. Surgical excision was required in 30% of patients in this series, with infrequent short-term recurrences. The cause is uncertain. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Ocular Surface Parameters in Older Male Veterans

To characterize ocular surface discomfort and tear film parameters in a veteran population. Male patients seen in the Miami Veterans Affairs eye clinic aged 50 years or older were recruited to participate in the study. All patients had normal eyelid, corneal, and conjunctival anatomy. Patients filled out the Dry Eye Questionnaire 5 (DEQ5) and underwent measurement of tear film parameters. The main outcome measures were the frequency of ocular surface symptoms and the correlation between symptoms and global, aqueous, and meibomian gland parameters. A total of 263 men participated in the study; 48% had DES based on the presence of severe symptoms. Many men had objective abnormalities in tear function measurements. Using Schirmer information, lid plugging, and meibomian quality to define objective DES, 176 patients (68%) had one or more abnormalities. Of these, 22 (8%) had aqueous tear deficiency, 124 (47%) lipid tear deficiency, and 30 (11%) a mixed pattern. When examining associations between individual clinical parameters and DEQ5 score, the only significant, but weak, correlations were with the global parameters conjunctival and corneal staining (r = 0.16) and TBUT (r = -0.15). Neither specific aqueous nor meibomian gland measurements were significantly correlated with the presence of symptoms. When considering all measured parameters in a regression model, 8% of the variability in symptoms was explained by the tear parameters. We found that ocular surface symptoms were prevalent in our population. Measurement of standard tear film parameters could not explain the degree of symptoms. This study highlights the need for future research regarding the mechanisms behind ocular surface discomfort in patients with tear film disturbances.

Quality of Life in Glaucoma Patients

Glaucoma affects the quality of life (QoL) of millions of people. Patients with glaucoma have a reduced QoL in early stage disease, which worsens as the disease progresses. Reduced visual function is the main determinant of poor QoL in glaucoma, however ocular surface discomfort, psychological factors, and social constraints contribute to the burden of disease. The assessment of QoL in glaucoma is important in clinical practice to assessing a patient’s wellbeing, visual function and level of satisfaction with their care. It can be used to make important therapeutic decisions and allow clinician and patient to share common, realistic goals leading to better treatment outcomes. Quality of life assessment is increasingly important in clinical research. Various tools have been used to assess QoL in glaucoma, including general health-related questionnaires, vision-specific questionnaires, glaucoma-specific questionnaires, utility value assessments and objective visual function assessment. These tools are summarized and critically appraised in this article.

Hormones and Dry Eye Disease

Dry eye disease (DED) is a very prevalent eye disorder, affecting 40 million people in the United States alone. The primary cause of DED is meibomian gland dysfunction (MGD) [1], which by itself is a disease entity. The meibomian gland is a large sebaceous gland located in the tarsal plate of the eye lids. It functions to synthesize and secrete lipids onto the ocular surface. These lipids make up the outer-most layer in the tear film and reduce tear evaporation. When the quantity or quality of the lipids is compromised such as occurs in MGD, tears evaporate more quickly, leading to increased DED, ocular surface discomfort, impaired vision and decreased quality of life.

Efficacy of a novel moist cool air device in office workers with dry eye disease

To evaluate the efficacy and safety of new moist cool air device (MCAD) for ocular symptoms, tear film stability and ocular surface status in office workers with dry eye disease (DED). In this prospective single-centre clinical trial, 40 eyes of 20 patients with DED were recruited and randomly divided into two groups (group with MCAD exposure and group without MCAD). All subjects are visual display terminals (VDTs) workers spending at least 4 h/day in front of VDTs. Patients using MCAD underwent moist air applications for 4 h/day for a total of five working weekdays during VDT works at their offices. The other group of patients performed their VDT work without moist cool air device exposure. The change in symptoms of ocular surface (OS) dryness, fatigue and discomfort was evaluated using visual analogue scale (VAS) scores. Changes in visual function, tear functions and ocular surface status were evaluated using best-corrected visual acuity (BCVA), the functional visual acuity (FVA) test, blink rate, BUT measurements, strip meniscometry (SM), tear evaporation rate, fluorescein staining and rose bengal staining scores. Tear film lipid layer interferometry was also performed to assess the status of the lipid layer over the tear film. In addition, adverse events were recorded. In group with MCAD, symptoms of OS dryness during VDTs work, and FVA and BUT were significantly improved. SM and tear evaporation rate were significantly improved. There were no statistically significant differences on lipid layer stability and corneal staining scores in both groups. Blink rate was significantly increased in group without MCAD. No adverse events were reported during this trial. Moist cool air device use provided symptomatic relief of ocular dryness and improvement on tear stability in office workers with DED. This new device seems to be a safe and promising alternative in the treatment of DED.

Indications and Outcomes of Amniotic Membrane Transplantation in the Management of Acute Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis

To evaluate the indications and outcomes of amniotic membrane transplantation (AMT) performed within the first 2 weeks of presentation in the management of patients with acute Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). A retrospective chart review from January 1998 to May 2011 identified 128 SJS/TEN patients admitted to Loyola University Medical Center Burn intensive care unit. The degree of initial ocular surface inflammation was graded as mild, moderate, or severe within the first 2 weeks of admission. Patients were managed either medically or with amniotic membrane (AM). Outcomes were graded as good [best-corrected visual acuity (BCVA)>20/40], fair (BCVA 20/40 to 20/200 or with ocular surface discomfort, requiring contact lens or reconstructive surgeries), or poor (BCVA<20/200). Of the 182 eyes (91 patients) with documented inpatient eye examinations, 108 eyes (59.4%) had mild or no initial ocular involvement, 37 eyes (20.3%) had moderate, and 37 eyes (20.3%) had severe inflammation. Of the 29 patients (58 eyes) with greater than 1 month of follow-up, 17 patients (33 eyes) were treated with medical management and 13 patients (25 eyes) were treated with early AM. One of the 23 eyes with moderate or severe presentation treated with early AMT (4.3%) resulted in a poor outcome within 3 months compared with 8 of 23 eyes (34.8%) that were medically managed (P=0.022). We present the first case-control study of the use of AM in the management of acute SJS/TEN. Early use of AMT prevents severe vision loss in SJS/TEN patients with initial moderate or severe ocular surface inflammation.

Correlation between tear osmolarity and the dry eye severity

Background There still is no a uniform diagnostic criteria for increasing population of dry eye.Studies showed that high tear osmotic pressure is one of causes of a variety of ocular surface discomfort,and the change of tear osmolality has been included in the definition of dry eye syndrome by Dry Eye World Study Group (DEWS) in 2007.It is very clinically significant to study the relationship of tear osmolality with dry eye.Objective This clinical trial was to study the correlation between tear osmolarity and dry eye severity based on Preferred Practice Pattern(PPP)of DEWS.Methods A descriptive study was performed.Fifty-four eyes of 54 patients with dry eye disease were asked to complete an evaluation of dry eye signs and symptoms questionnaire based on PPP.The ocular anterior segment was examined under the slit lamp biomicroscope.Cornealfluorescein staining,tear-film breakup time (BUT),Schirmer test Ⅰ (S Ⅰ t)without anesthesia were performed,and tear sample was collected for tear imageology and tear osmolarity admeasurement.The correlation between dry eye score with tear osmolarity was evaluated using Pearson linear correlation analysis.Written informed consent as obtained prior to any relevant medical procedure.Results The ratio of male and female patients was 1: 2 in this study.The negative correlations were found between tear osmolarity with S Ⅰ t or BUT(r =-0.456,-0.699,P＜0.01),and significantly positive correlations were found between tear osmolarity with tear imaging examination,corneal fluorescein staining,conjunctival hyperemia or dry eye symptom score(r=0.545,0.686,0.691,0.803,P＜0.01).Conclusions As a diagnostic method,tear osmolarity can objectively reflects dry eye severity.It can be a biomarker in dry eye severity grade when combined with clinical symptom. Key words: Dry eye; Tear osmolarity; Ocular surface