OVS Announces Feature Issue: Dry Eye Disease - September 2015

 Coming in the September 2015 Optometry & Vision Science

Feature Issue: Dry Eye Disease

Here are brief highlights.
The online and printed copy will be available early-September.
E-Publication Ahead-of-Print now available for all these articles at

Anthony J. Adams, OD, PhD, FAAO


Isotretinoin Even if No Dry Eye Symptoms? 

The authors review the etiology and longstanding consequences of isotretinoin use in the development of dry eye symptoms in the absence of significant clinical findings. Meibomian gland expression is crucial in isotretinoin-associated dry eye to determine whether the secretory function is reduced, as demonstrated by poor meibum quality or quantity. The authors argue there is no guaranteed method to restore structure and function of all damaged meibomian glands and that consequently treatment options for isotretinoin-associated meibomian gland dysfunction are primarily palliative.

Dry Eye Amenable to Genetic and Proteomic Studies?

Mucins are an important component of a healthy tear film. The authors summarize mucin expression in the lacrimal functional unit and how it may be altered in dry eye disease. They argue that while mucin expression in the normal ocular surface has been well explored, mucin changes in dry eye disease are inconsistent and may result from changes in glycosylation rather than the mucins themselves. They propose genomic and proteomic studies to identify new avenues for exploration.

Dealing with Advanced Dry Eye

Although many dry eye patients can be satisfactorily managed using traditional approaches such as artificial tears, punctal plugs, oral doxycycline, and other measures, a subset of this population fail to respond. The authors' review considers contemporary procedures for treatment of advanced cases, including thermal and electrocautery of the lacrimal puncta, lid surgeries such as tarsorrhaphy, and procedures to protect the exposed or compromised ocular surface.

Omegas and Dry Eye: More Knowledge, More Questions

In 2011 the average cost of managing dry eye disease (DED) was estimated at $55.4 billion, considering both healthcare costs and loss of productivity costs. Many individuals already take omega 3 PUFAs for DED- a massive expenditure without strong published evidence of efficacy. Our authors call for more evidence-based studies on the usefulness of OTC supplements to allow confident treatment recommendations for omega 3 PUFAs in DED.

Pragmatic Dry Eye Management

Dry eye disease is a highly prevalent, chronic ocular disorder and a potentially debilitating condition. Management options are numerous. By considering two dry eye case scenarios, our authors' review presents a pragmatic clinical approach to best-practice evidence-based management of dry eye patients.

Risk Factors For Dry Eye Syndrome 

Our authors note that prior studies obscure some risk factors by addressing the epidemiology of dry eye from cross-section study analysis. They believe their case-controlled study is a 'first' and that it identifies significant risk factors that allow them to re-classify the dry eye syndrome.

Meibomian Gland Function and Contact Lenses

In a multicenter, matched-paired, study our authors analyzed how contact lens use was related to meibomian gland atrophy and the ocular surface. They found inconclusive associations with contact lens use and meibomian gland atrophy. However, they believe their data may help industry develop healthier contact lenses and provide a basis for longitudinal progression studies on meibomian gland atrophy.

Misdiagnosing Contact Lens Dry Eye

Are we misdiagnosing uncomfortable contact lens wearers?  Though contact lens (CL) related dry eye patients can have significant symptoms, signs of dryness, however, are often absent. These patients may discontinue CL wear. But dry eye and binocular vision disorders share several common symptoms and the authors’ raise the question of whether some diagnosed "dry eye symptoms" may be a consequence of binocular vision disorders that lead to discontinuation of CL wear.

Anti-Glaucoma Drops and Dry Eye Symptoms

The authors study ocular surface disease and find it is common in topical anti-glaucoma medication users.  They found symptoms increased with increasing numbers of eyedrops and benzalkonium chloride-containing eyedrops.

Glaucoma Medication Use and Dry Eye

In this case-controlled study, the authors note that dry eye is associated with glaucoma medications and revealed that an increased number of glaucoma medications, particularly in individuals who use more than 2 types of glaucoma medications, increased dry eye risk, particularly in females.

Dry Eye Syndrome After LASIK May be Neuralgia Induced

Our authors present three cases that illustrate that corneal neuralgia may be the basis for refractory dry eye syndrome after Laser-Assisted in situ Keratomileusis (LASIK).

Can Incomplete Blinks be the Dry Eye Culprit?

Our author not only says "Yes", but his review suggests prophylactic and post-LASIK blink exercises reduce incomplete blink rates could prevent or reduce symptoms and signs of dry eye and facilitate faster wound healing.

Tear Film Cooling and Tear Breakup Go Hand in Hand

By simultaneously imaging ocular surface temperature and fluorescein tear breakup (FTBU) our authors find cooling of the ocular surface correlates with FTBU. They suggest tear film evaporation is responsible for both processes and that the combined measures could provide an indication of the level of evaporative stress the tear film can sustain, aiding in diagnosis, monitoring and management of evaporative dry eye.

Automated Tear Break Up Objectively Compared to Subjectively

The Keratograph 4 can assess the tear film objectively without the installation of fluorescein (NIK-BUT). In the authors study of 60 participants, measures reported by the Keratograph were found to be longer on average compared to the traditional subjective tear break up time measure with fluoroscein (FTBUT), but both measures have poor repeatability.  They suggest the Keraograph 4 and traditional TBUT measures should be used in combination with other dry eye measures when assessing the effectiveness of treatment(s) in clinical practice.

Tear Film Stability, not Osmolarity, Related to Dryness Symptoms

In 137 university campus dry eye participants, the authors sought the relationships of tear osmolarity, tear film stability, and dry eye symptoms using a multivariable analysis in a cross-sectional study. In this population of young mild to moderate dry eye patients (68 non-contact lens wearers, 69 soft CL wearers), it was found that while shorter tear breakup times were significantly associated with dry eye symptoms, osmolarity was not.

Accuracy of a Freezing Point Depression Technique Osmometer

Using a freezing point depression technique (Fiske 110 Osmolarity System) the authors found osmolarity measure performance was good in undiluted lens care solutions and acceptable for diluted samples close to tear osmolarity values. Worse performance was observed for more diluted samples.

Climate Significant in Dry Eye Diagnosis

Perhaps not surprisingly, this pilot study showed that the ocular surface integrity of similar non-symptomatic participants depends on the climate. The variation in environmental conditions (Atlantic versus Continental climate) can negatively impact the healthiness of the ocular surface and decrease the reliability of common dry eye disease tests. This absence of consistency undermines diagnosis of dry eye disease and possible dry eye disease clinical trials outcomes.

Corneal Confocal Microscopy Predicting Dry Eye Treatment Success with Corticosteroids?

The authors used in vivo laser scanning confocal microscopy (LSCM) corneal findings in moderate-to-severe dry eye patients before and after treatment with topical corticosteroid.  Their results suggest that LSCM measures might be shown to be good predictors of the responsiveness to corticosteroid treatment in moderate to severe dry eye patients in a larger study population.

Comparison of Topical Cyclosporine and Diquafosol Treatment

Our authors compare the treatment effects of topical cyclosporine A (CsA) and diquafosol sodium (DQS) for the treatment of moderate to severe dry eye disease (DED) in a nonrandomized prospective study of 60 patients. They found both topical CsA (0.05%) and DQS (3%) to be effective but the timing and degree of therapeutic effects on tear film and ocular surface parameters, as well as the symptoms, can be different between the two treatments.

Intraocular Scattering Decreased with Diquafosol

Intraocular scattering increases significantly with time in patients with short TBUT dry eye. However diquafosol ophthalmic solution treatments over 4 weeks revealed an improvement not only in TBUT, but also in intraocular scattering, indicating  diquafosol is also effective for improving the optical quality of the eye.

Prompted Blinking Improves Dry Eye Computer Symptoms

Dry eye during computer use blink rate is reduced about 50% and the dry eye consequences are a growing concern worldwide. The authors found that a novel software animation, "blink blink", prompting a double blink, increases blink rate and improves dry eye symptoms during computer use. The software is available from the corresponding author without charge (daniela.nosch@fhnw.ch).

Lid Debridement-Scaling in Sjögren's Syndrome

The authors show lid debridement-scaling (LDS) improved dry eye symptoms, ocular staining and meibomian gland function in patients with Sjögren's Syndrome (SS) and can aid in the management of SS dry eye.

Self-Applied Heat Therapies Compared for Meibomian Gland Dysfunction

Tear film and ocular surface characteristics were compared following a single application of two commercially available warm compresses: an eye mask (Eyegiene) and an eye bag (MGDRx Eye Bag), in 41 participants with mild-to-moderate dry eye symptoms. Application of both devices resulted in clinically and statistically significant increases in tear film stability and lipid layer grade. The MGDRx Eye Bag was the more effective in raising ocular temperature, and was the preferred treatment method among subjects.

Warm Compresses Are Not Equally Efficacious

Meibomian gland dysfunction (MGD) is thought to be the leading cause of dry eye throughout the world and this growing awareness of the implications of untreated MGD is paralleled by the need for similar expansion and growth in management approaches.   Patients are aware of the benefits and limitations of home therapy, but not all home therapies are equally effective.

Thermal Pulsation Therapy for Dry Eye Patients

Our authors study dry eye symptoms (Standard Patient Evaluation of Eye Dryness -SPEED) and signs- including non-invasive tear break up time (NITBUT) and meibomian gland dysfunction following use of the LipiFlow Thermal Pulsation System. NITBUT, meibomian gland expressibility and SPEED all improved, particularly for females, and the authors note their results identify which patients will benefit most from this therapy.

Dry Eye Care: What the Experts Say

Many ocular surface conditions share the same dry eye symptoms making the establishment of the root cause challenging. Clinician scientist experts discuss etiology, diagnosis, treatment, and management of patients who experience dry eye symptoms. They include "crystal ball forecasting" on future advancements over the next decade and beyond.

Dry Eye Diagnosis Challenged

Meibomian gland dysfunction (MGD) is arguably the leading cause of dry eye. The authors’ believe our clinical perspective is limited by our failure to use an etiology-based, as opposed to a signs and symptoms-based, approach to managing dry eye. They believe MGD is the primary diagnosis and treatments should be directed toward rehabilitating and restoring meibomian gland function.