Giuseppe Giannaccare

Sex-Steroid Imbalance in Females and Dry Eye

Abstract Dry eye (DE) is a multifactorial disorder of the ocular surface unit that results in eye discomfort, visual disturbance and ocular surface damage. It is one of the most common complaints in daily ophthalmic practice. The risk of DE increases with age in both sexes, while its incidence is higher among females. In addition, the condition of menopause in aging women may also contribute to DE onset or worsening as a consequence of an overall hormonal imbalance. Sex hormones play a key role in ocular surface physiology and they impact differently on ocular surface tissues. Reduced estrogen levels were historically thought to be responsible in age-related DE onset but more recent investigations have reconsidered the role of androgens that are present and exert a protective function on the ocular surface. Hormone levels themselves, withdrawal changes in hormone levels, and the changes in hormone-receptor responsiveness are all important factors but it remains to be fully elucidated how estrogen or androgen insufficiency act alone or together in a combined imbalance or interplay to raise the risk of disease. The purpose of this review is to briefly outline current scientific evidence on the influence of androgens and estrogens, on the Lachrymal and Meibomian glands and on ocular surface epithelia including conjunctival goblet cells during reproductive and menopausal periods. The role of sex steroids is also discussed in relation to the pathogenesis of different forms of DE and Sjogren’s syndrome (SS). The impact of systemic hormone therapy (HT) in DE post-menopausal women still appears as a controversial issue, despite the many clinical studies. Finally, the outcomes of topical applications of steroid-based products are summarized, underlying the need for potential (tear) biomarker(s) in the rationale of DE-targeted therapy.

Subjective Discomfort Symptoms Are Related to Low Corneal Temperature in Patients With Evaporative Dry Eye.

Purpose: To measure the corneal temperature in patients with dry eye (DE) and to correlate the values with subjective discomfort symptoms. Methods: Twenty-four patients with DE (scored as DEWS severity grade 2 to 3) and 15 age-matched normal control subjects were enrolled. Subjective symptoms of discomfort were scored with an Ocular Surface Disease Index questionnaire, and a 100-mm horizontal visual analog scale (VAS) technique was used to measure symptom intensity. Schirmer I test, tear film breakup time (TFBUT), and Oxford grade scoring were performed in all subjects. Dynamic infrared noncontact thermal imaging (Tomey TG 1000) was used to measure the central corneal temperature (CCT). After training, subjects were asked to maintain their eyes forcedly open and to signal the discomfort onset time (DOT). The temperature was measured at eye opening (T0) and every second during 10 seconds of sustained eye opening (T10). The first discomfort sensation onset time (DOT) was also recorded. Temperature values were correlated with the clinical tests, Ocular Surface Disease Index, VAS, and DOT, and data were statistically evaluated (significance P < 0.05). Results: The corneal temperature immediately after eye opening was significantly lower in patients with DE than in controls, in correlation to the subject age, VAS, and TFBUT. A 3-phase cooling profile in patients with DE and a point of highest decrease (HD) in both groups were identified. DOT occurred earlier in patients with DE than in controls (5.9 vs. 15.9 seconds) and was strongly correlated to the VAS, TFBUT, and CCT-HD. Conclusions: Subjective sensation of discomfort occurred earlier in patients with DE than in controls, in correlation to low corneal temperatures and enhanced tear evaporation.

Dry Eye Disease Is Already Present in Hematological Patients Before Hematopoietic Stem Cell Transplantation.

Purpose: To analyze ocular surface parameters in patients before hematopoietic stem cell transplantation (HSCT) and to correlate them with hematological characteristics. Methods: This is a retrospective analysis of prospectively collected data from 203 patients undergoing HSCT. Demographic data and hematological parameters (disorder type and stage) were collected from clinical charts. Ocular surface parameters (ocular surface disease index; Schirmer test I; tear film break-up time; corneal esthesiometry; and corneal and conjunctival staining) were analyzed the day before beginning the conditioning treatment for HSCT preparation. Results: A high prevalence of dry eye (DE) was found: 116 patients (57.2%) were diagnosed as not suffering from DE, whereas 87 patients (42.8%) were diagnosed as having DE. Of these, 26 were classified as dry eye workshot (DEWS) severity score 1, 46 as DEWS score 2, and 15 as DEWS score 3. Tear film break-up time was found to be the only parameter statistically worse in the chronic lymphoproliferative disorder group compared with the stem cell malignancy group. Older age [odds ratio (OR) 1.03], female sex (OR 2.03), advanced stage of hematological disease (OR 1.4), and previous auto- or allo-HSCT (OR 1.9) showed a significant positive association in predicting DE onset before transplantation. Conclusions: DE was already present in a significant number of patients suffering from hematological disease before HSCT. Some hematological parameters seemed to influence this percentage. These results highlight the role of ocular surface examination by an ophthalmologist in hematological patients before HSCT, with the aim of diagnosing and, if necessary, treating DE patients early.

Targeting growth factor supply in keratopathy treatment: comparison between maternal peripheral blood and cord blood as sources for the preparation of topical eye drops

BACKGROUND Epitheliotrophic growth factors (GF) can be supplied topically to patients with severe keratopathy through a variety of blood-derived products. We compared GF content in adult peripheral blood serum (PB-S) and cord blood serum (CB-S) as potential sources of GF. To limit inter-individual variability the assessment was performed in maternal-child pairs at the time of delivery. MATERIAL AND METHODS The amounts of epidermal GF (EGF), insulin-like GF (IGF), transforming GF-beta (TGF-β), vascular endothelial GF (VEGF) in CB units collected from the umbilical vein and PB from mothers (each group n=30) were estimated by enzyme-linked immunosorbent assays. Obstetric characteristics and haematological data were recorded from the archives of the Emilia Romagna Cord Blood Bank. Statistical evaluations were performed by Wilcoxons test and correlations between variables were determined using Spearmans (ρ) coefficient; p-values <0.05 were considered statistically significant. RESULTS EGF, TGF-β and VEGF levels were significantly higher in CB-S than in PB-S (median 1,254.4 vs 646.0 pg/mL, 51.3 vs 38.4 μg/mL and 686.8 vs 30 pg/mL, respectively; all p<0.0001) whereas IGF content was significantly higher in PB-S than in CB-S (159.9 vs 53.5 pg/mL, respectively; p<0.0001). In CB-S, the CD34(+) cell concentration appeared to be related to EGF, IGF and TGF-β levels whereas white blood cell count appeared to be related to EGF and TGF-β levels. VEGF levels showed no relation to the haematological parameters considered. Platelet counts were not related to GF level in either CB or PB. DISCUSSION The GF content in the two blood sources was different, with CB containing larger amounts. Each GF selectively regulates cellular processes involved in corneal healing, so the use of PB or CB should be targeted to supply specific GF on the basis of the type and severity of the keratopathy.

Cord blood serum-based eye drops: the impact of donor haematological and obstetric factors on the variability of epidermal growth factor levels.

BACKGROUND Cord blood serum (CBS)-based eye drops are successfully used in corneal epithelial wound healing and are prepared to supply a known amount of epidermal growth factor (EGF). Product standardisation includes expensive EGF dosage in all cord blood (CB) units. The influence of donor obstetric and haematological characteristics on EGF content was evaluated, to exclude unsuitable CBS and pre-select those CB units able to provide the correct EGF supply for healing corneal wounds. MATERIALS AND METHODS Data were retrospectively collected from 135 donors included in the Emilia Romagna Cord Blood Bank records. Obstetric characteristics, parity and gestational age of the mother, sex, birth weight and Apgar score of the neonate, placental weight, duration of labour and mode of delivery were considered. Haematological characteristics, CD34+ cell number, and total nucleated cell, white blood cell and platelet counts were recorded. EGF content in CB units was estimated by enzyme-linked immunosorbent assay. Statistical evaluation was performed by Mann-Whitney unpaired and Students t tests. Correlations between variables were evaluated by using Pearsons (r) or Spearmans (ρ) correlation coefficients. RESULTS EGF content was significantly higher in CBS from donors aged <30 years and after vaginal deliveries as compared with scheduled Caesarean sections (1,386±580 vs 1,106±391 pg/mL; P=0.002). EGF content was significantly correlated with duration of labour (r=0.45; P=0.0001), number of CD34+ cells/mL (r=0.3; P=0.002) particularly in vaginal deliveries (r=0.36; P=0.003), mothers age (-0.25; P=0.005), neonates birth weight (r=0.27; P=0.005), and total nucleated cell (r=0.25; P=0.006), white cell (r=0.29; P=0.001) and platelet (r=0.24; P=0.009) counts. No significant correlations were found between EGF content and parity, gestational age, placental weight, neonates sex or Apgar scores. DISCUSSION EGF levels are higher in CB units from younger mothers (<30 years), with longer labour duration (>6 hours), and higher CD34+ cell content (>0.05×10(6)/mL). In order to optimise the preparation and costs of CBS-based eye drops, pre-selection of CB units is recommended.

Discomfort symptoms reduction and ocular surface parameters recovery with Artelac Rebalance treatment in mild-moderate dry eye.

Purpose To evaluate Artelac Rebalance® eyedrops’ efficacy in symptoms reduction, ocular surface parameters recovery, and tolerability in the treatment of mild to moderate dry eye. Methods Fifteen patients were enrolled. Inclusion criteria were Ocular Surface Disease Index (OSDI) score >16, tear film break-up time (TFBUT) <10 seconds, Schirmer test I >10 mm/5 min, and mild ocular surface damage (Oxford grading) ≤3. Artelac Rebalance® eyedrops were administered 3 times daily for 2 months. Patients were evaluated at enrollment, after 2 days of washout (baseline), and after 1 and 2 months of treatment. Parameters for ocular discomfort (OSDI score), tear film quality (Schirmer test I, TFBUT, tear osmolarity), ocular surface damage (fluorescein staining, conjunctival imprint cytology), and inflammation (scraping cytology and exuded serum albumin) were measured. Tolerability and satisfaction were assessed by validated questionnaires. Results At endpoint versus baseline, all variables showed a statistically significant improvement (paired Student t test, p<0.01 for all parameters) as follows: OSDI score (21.9 ± 10.6 vs 35.8 ± 12.2), TFBUT (6.5 ± 1.1 s vs 5.2 ± 2.3 s), Oxford grading of corneal and conjunctival damage (0.56 ± 0.50 vs 1.16 ± 0.37), tear osmolarity (294.6 ± 2.1 mOsm/L vs 303.1 ± 4.6 mOsm/L), conjunctival goblet cell density/mm2 (140.8 ± 43.3 cells/mm2 vs 115.1 ± 15.8 cells/mm2), scraping cytology score (2.9 ± 1.0 vs 4.2 ± 1.3), and percentage of serum albumin in tears (9.2% ± 4.8% vs 24.1% ± 10.8%). Tolerability and satisfaction were scored high, with no adverse events reported. Conclusions Application of Artelac Rebalance® eyedrops for 2 months in mild to moderate dry eye resulted in a reduction of ocular inflammation parameters, ocular surface damage, and subjective discomfort symptoms, with a parallel improvement in tear film quality (measured by TFBUT and osmolarity).

Synergistic effect of regenerating agent plus cord blood serum eye drops for the treatment of resistant neurotrophic keratitis: a case report and a hypothesis for pathophysiologic mechanism

This report describes a case of a 72-year-old Caucasian woman presenting with a large neurotrophic keratitis with a large persistent epithelial defect, with a longest linear diameter of 7 mm and greatest perpendicular width of 5 mm, affecting epithelium, Bowman membrane, and anterior stroma. Corneal disease was resistant to conventional treatment and classified as stage 2 according to Mackie classification. Patient was instructed to instill regenerating agent (RGTA) eye drops in the morning, as the first eye drop, once every 5 days in combination with daily cord blood serum (CBS) eye drops 6 times/day. The patient was asked to visit after 1 week (V1), 2 weeks (V2), 3 weeks (V3), and 4 weeks (V4) of study treatment. In V4 treatment, corneal sensitivity improved, and keratitis healed with resolution of stromal inflammation. Global treatment tolerance was very satisfactory. Patient continued the therapy for a further month after complete healing. Currently, the patient has been followed up for 3 months without any sign of keratitis recurrence. To the best of our knowledge, this case report describes for the first time the successful combined use of RGTA and CBS eye drops for the treatment of neurotrophic keratitis resistant to conventional treatment. We hypothesize that RGTA eye drops could provide an optimal migration substrate and that growth factors supplied by CBS eye drops could strengthen the repair process by promoting cell growth over the matrix. Combined RGTA and CBS eye drop therapy could be a new potential option for the successful treatment of resistant neurotrophic keratitis, particularly when each drug alone is not effective.

Photorefractive keratectomy in 22 adult eyes with infantile nystagmus syndrome.

Purpose To analyze visual and refractive outcomes of photorefractive keratectomy (PRK) in adult patients with infantile nystagmus syndrome. Setting Ophthalmology Unit, Department of Experimental Diagnostic and Specialty Medicine, Saint Orsola‐Malpighi Hospital, University of Bologna, Bologna, Italy. Design Retrospective case series. Methods Photorefractive keratectomy was performed in both eyes of patients with infantile nystagmus syndrome under topical anesthesia using an eye‐tracking excimer laser. Patient satisfaction was tested using a questionnaire. The main outcomes were a decrease in refractive error, an improvement in postoperative corrected distance visual acuity (CDVA), and an uncorrected distance visual acuity (UDVA) equal to or better than the preoperative UDVA. Results Twenty‐two eyes of 11 patients with infantile nystagmus syndrome were evaluated. The mean patient age was 30.82 years (range 22 to 42 years). All eyes had simple, compound, or mixed astigmatism (mean −3.40 D; range −0.75 to −6.00 diopters [D]). The mean postoperative astigmatism (−0.70 D ± 0.81 [SD]) and spherical equivalent (−0.420 ± 0.652 D) were statistically significantly better than the preoperative values (−3.40 ± 1.31 D and −3.426 ± 3.343 D, respectively (P < .0001 and P = .0002, respectively). The mean monocular postoperative CDVA (0.24 ± 0.19 logMAR) and UDVA (0.25 ± 0.18 logMAR) were better than the mean preoperative CDVA (0.32 ± 0.28 logMAR) (P = .0045 and P = .0338, respectively). The mean binocular postoperative UDVA was better than the mean preoperative CDVA (0.15 ± 0.14 logMAR versus 0.23 ± 0.23 logMAR) (P = .05). No patient required repeat surgery. Conclusions Nystagmus patients are eligible for PRK. The results were promising; gaining a few Snellen lines in visual acuity can be very important to these patients for their daily life. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Blood derived eye drops for the treatment of cornea and ocular surface diseases

The use of blood derived eye drops for the treatment of ocular surface disorders has become increasingly popular in recent years. The mechanism of action is the stimulation of cellular proliferation and migration by supplying an active mixture of growth factors and cytokines at the ocular surface, thus mimicking the function of the lacking natural tears. Blood derived eye drops have been used in the last decades for the treatment of a variety of ocular surface diseases, including mainly dry eye disease, persistent corneal epithelial defect, corneal ulcer, ocular surface burn, recurrent corneal erosion and limbal stem-cell deficiency. Among overall blood derived eye drops, both autologous (from the patients themselves) and homologous (from donors) products exist, with different advantages and disadvantages. Autologous serum, obtained from the patients own peripheral blood, is the first introduced and most commonly used product. Despite several randomized clinical trials showed its safety and efficacy, a recent Cochraine meta-analysis failed to show significant results due to low evidence. Homologous sources including allogeneic serum obtained from healthy donors, and umbilical cord blood serum collected at the time of delivery, are efficient alternatives, especially when autologous serum therapy is contraindicated or not appropriate. Platelet-derived eye drops are prepared and used in various but poor standardized preparations, namely platelet-rich plasma, plasma rich in growth factors, and platelet lysate. Future perspectives of blood-derived products include the introduction of tailored eye drops, screened for the proper content of growth factors and cytokines according to each patient and ocular surface disease.

Ocular-surface temperature modification by cataract surgery

Purpose To analyze ocular‐surface temperature changes after microincision cataract surgery and to correlate them with surgical, clinical, and laboratory parameters. Setting Ophthalmology Unit, Saint Orsola‐Malpighi Hospital, Bologna, Italy. Design Prospective case series. Methods Patients affected by monolateral senile cataract were examined preoperatively and 7 days and 28 days postoperatively. Infrared thermography was used to measure the temperature soon after eye opening, the temperature after 10 seconds of sustained eye opening, and the difference between these 2 values in the central cornea, nasal limbus, and temporal limbus. The Ocular Surface Disease Index (OSDI), Schirmer test, vital staining, tear breakup time (TBUT), conjunctival scraping cytology, exudated tear‐serum albumin, and laser flare–cell meter examinations were performed. Results The study comprised 26 patients (10 men, 16 women). The temperature changed significantly after surgery. The temperature soon after eye opening showed cooling in the central cornea and nasal limbus and heating in the temporal limbus. The temperature after 10 seconds of sustained eye opening minus the temperature soon after eye opening increased in all regions. The temperature after 10 seconds of sustained eye opening minus the temperature soon after eye opening in the central cornea was inversely related to the OSDI and directly related to TBUT. The temperature soon after eye opening increased in the temporal limbus and was directly related to inflammatory indices. Conclusions The ocular‐surface temperature changed after cataract surgery depending on the region analyzed. The cooling in the central cornea could be related to the increased tear‐film instability. The heating in the temporal limbus could be related to postoperative inflammation. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.