Aims/Purpose: The aim of the study is to evaluate with SEM the residence time and ultrastructural effects on the ocular surface cells in patients suffering from dry eye disease (DED) treated with a multiple‐acting tear substitute based on 0.15% cross‐linked HA, cationic liposomes and 3% trehalose (Trimix®, Offhealth SpA, Firenze, Italy).Methods: We examined 10 eyes of 10 patients with previous clininal diagnosis of DED (Schirmer test 1 < 10 mm, TBUT < 10 s, OSDI > 13). Exclusion criteria: topical or systemic therapies in the previous 30 days; allergic conjunctivitis; infections and other ocular surface diseases in the last 3 months; previous herpetic keratitis; corneal opacities and ulcers; pregnancy and breastfeeding, age < 18 years.All patients were treated for 30 days BID with Trimix®. At the baseline (T0) and 1h (T1), 6h (T2) and 12h (T3) after the end of the treatment, a cytological sampling of the bulbar conjunctiva with an impression procedure was performed. The cytological smear was examined with SEM for the evaluation of the microvilli, using a preset scale (Del Prete, 2017), and of the persistence of Trimix®, preliminarily identified by SEM on a slide. The results were compared with a control group (CTR) of 10 patients with the same grades of inflammation of DED group, treated with BID balanced salt solution.Results: At T0 6 DED patients presented mild/moderate inflammation (grade 1‐2 of microvillar alteration); 4 medium/severe inflammation, with grade 3‐4 on the microvillar evaluation. At T1 8/10 eyes (80%) showed a complete restoration of the microvillar surface (p < 0.001), 2/10 (20%) an improvement at stage 1 (p < 0.001). The persistence of the Trimix® molecules was detected at T1 and T2 in all cases; in 9 of them (90%) Trimix® partially enveloped the microvilli at T3. No significant microvillar changes were found in CTR group (p > 0.05). The tear substitute resulted well tolerated as no patient reported any significant side effects.Conclusions: Microvilli express the vitality of epithelial cells. Their significant improvement or complete recovery after treatment with Trimix® indicates strong trophic and protective properties of the product, that could continue even 12 hours after the instillation, as confirmed by the high residence time. This could suggest a high effectiveness even when administered twice daily.
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