Julie Albietz

Prevalence of dry eye subtypes in clinical optometry practice.

Background Dry eye conditions are now recognized as having multiple causes. A subtype-based dry eye diagnostic protocol was developed to determine the prevalence of dry eye and dry eye subtypes, and the effects of age and gender, in subjects presenting to clinical optometry practice. Methods Dry eye diagnostic criteria were: presence of one or more McMonnies dry eye survey primary symptoms, fluorescein tear break time <10 s and rose bengal ocular surface staining. Dry eye subtype differential diagnosis was made predominantly on the basis of biomicroscopic signs. Subtype categories were: lipid anomaly dry eye (LADE), aqueous tear deficiency (ATD), primary mucin anomalies, allergic/toxic dry eye (ADE), primary epitheliopathies and lid surfacing/blinking anomalies (LSADE). Results Dry eye prevalence was 10.8% for n = 1584 subjects. Dry eye was significantly more prevalent in subjects 40 years or older (18.1%) compared with those <40 years (7.3%) (p = 0.001). LADE was the most prevalent subtype (4.0%), followed by ADE at 3.1%, LSADE at 1.8%, and ATD at 1.7%. ATD was the only subtype with a significant gender prevalence difference, being more prevalent in women (p = 0.0023). The prevalence of LADE and ATD were significantly greater in those 40 years or older (p = 0.001 and p = 0.0023 respectively). Conclusions The results of this study support a subtype-based approach to dry eye diagnosis and management in clinical practice.

Effect of Laser in situ Keratomileusis for Hyperopia on Tear Film and Ocular Surface

PURPOSE To examine the effects of laser in situ keratomileusis (LASIK) for hyperopia on the tear film and ocular surface. METHODS A retrospective 12-month analysis of 88 eyes (88 participants) who had LASIK for hyperopia was performed. Participants were evaluated before and after (2 weeks, 1, 3, 6, and 12 months) surgery for dry eye symptoms (McMonnies Dry Eye Survey primary symptoms), tear film stability (fluorescein break-up time), tear volume (phenol red thread test), ocular surface staining (fluorescein), and conjunctival goblet cell density. RESULTS Chronic dry eye was experienced by 32% of participants; symptoms were significantly associated with female gender, preoperative dry eye symptoms, lower tear film stability after surgery, greater ocular surface staining after surgery, lower tear volume before and after surgery, and lower goblet cell densities after surgery. Regression rate 12 months after surgery was 32% and significantly associated with female gender, chronic dry eye symptoms, lower tear film stability after surgery, greater ocular surface staining before and after surgery, and lower tear volume before and after surgery. CONCLUSIONS Dry eye, particularly in females, is problematic after LASIK for hyperopia and is associated with refractive regression. Current methods for managing the tear film and ocular surface may not control LASIK-induced dry eye, particularly in some females during the first 6 months after surgery.

Chronic dry eye and regression after laser in situ keratomileusis for myopia.

Purpose: To examine the relationship between chronic dry eye and refractive regression after laser in situ keratomileusis (LASIK) for myopia. Setting: Excimer Laser Vision Centre and Centre for Eye Research, Queensland University of Technology, Brisbane, Australia. Methods: This study was based on a retrospective analysis of a clinical database and a case study series. Data (N = 565 eyes) were collected before and after (2 weeks and 1, 3, 6, and 12 months) LASIK. Three case studies, which highlight appropriate management strategies for LASIK candidates with dry eye, are presented. Results: Regression after LASIK was related to chronic dry eye. It occurred in 12 (27%) of 45 patients with chronic dry eye and in 34 (7%) of 520 patients without (P<.0001). Patients with chronic dry eye had significantly worse myopic outcomes than those without (1 month, P = .02; 3 months, P = .01; 6 months, P = .004; 12 months, P = .008). The risk for chronic dry eye was significantly associated with female sex, higher attempted refractive correction, greater ablation depth, and the following pre‐LASIK variables: increased ocular surface staining; lower tear volume, tear stability, and corneal sensation; and dry‐eye symptoms before LASIK. The risk for regression was significantly associated with higher attempted refractive correction, greater ablation depth, and dry‐eye symptoms after LASIK. Case studies demonstrated that intensive dry‐eye treatment may improve the refractive outcome and alleviate the need for enhancement surgery. Conclusion: The risk for refractive regression after LASIK was increased in patients with chronic dry eye.

Dry eye after LASIK: Comparison of outcomes for Asian and Caucasian eyes

Background: Dry eye is a common complication of LASIK surgery. Our clinical impression was that post‐LASIK dry eye was more problematic for our Asian patients. The aim of this study was to determine if dry eye after LASIK is more prevalent, more sustained and more severe in Asian eyes compared with Caucasian eyes.

The conjunctival epithelium in dry eye subtypes: Effect of preserved and non-preserved topical treatments

Purpose. To determine the effect of topical treatments on the conjunctiva in dry eye. Methods. N = 134 dry eye subjects were diagnosed using a protocol of McMonnies dry eye symptom survey score > 14, fluorescein break up time (FBUT) < 10s and presence of rose Bengal staining. Differential diagnosis of dry eye subtypes was based on biomicroscopic signs and ocular/medical history. Superficial perilimbal bulbar conjunctival epithelial samples were collected using impression cytology. The nucleo-cytoplasmic ratio (N/C), goblet cell density (GCD) and expression of monoclonal antibodies HLA DR and CD23 were determined. The ocular surface characteristics of untreated subjects, those receiving preserved dry eye treatments and those receiving non-preserved treatments were compared with each other and with controls. Ocular surface characteristics of dry eye subtypes were also examined. Results. An increase in N/C (p = 0.011), reduction in GCD (p = 0.0001) and increase in expression of HLA DR (p = 0.0001) and CD23 (p = 0.0001) were detected in the untreated group compared to controls. No significant differences were found between the group receiving non-preserved dry eye treatments and untreated dry eye group. The group receiving preserved treatments had a reduced GCD (p = 0.0003) and increased expression of HLA DR (p = 0.0003) and CD23 (p = 0.0001) compared to the group receiving non-preserved treatments. Dry eye subtype specific differences in HLA DR and CD23 expression were noted. Conclusions. The conjunctival inflammation and reduced goblet cell density of dry eye is exacerbated by use of preserved topical agents, and is not significantly improved by use of non-preserved artificial tear supplements alone. Therapeutic strategies for dry eye should aim to increase goblet cell density and control ocular surface inflammation.

Ocular Surface Management of Photorefractive Keratectomy and Laser in situ Keratomileusis

PURPOSE To examine the effects of keratorefractive surgery and ocular surface management on goblet cell density, dry eye symptom incidence, and spherical equivalent refraction. METHODS We performed a retrospective analysis of four myopia groups: Untreated controls (n = 53); PRK (n = 51); LASIK without ocular surface management (n = 56); LASIK with ocular surface management (n = 140). 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 punctal plugs were used on indication. Assessments were conducted before and up to 12 months after surgery (right eyes only in patients with both eyes operated, and in the left or right eye in patients with one eye operated). RESULTS Surgery caused a significant reduction in goblet cell density, with the greatest reduction in the LASIK without ocular surface management group. No significant differences were detected in dry eye symptoms or spherical equivalent refraction between PRK and LASIK without ocular surface management. Ocular surface management significantly minimized LASIK-induced decreases in goblet cell density and was associated with significantly less myopic outcomes at months 1 to 3 and 6 to 9 after LASIK. After surgery (1 to 3 mo), dry eye symptoms were significantly lower in the LASIK with ocular surface management group. In all groups, significant inverse correlations existed between goblet cell density and dry eye symptoms. CONCLUSIONS Ocular surface management minimized the negative impact of LASIK on goblet cell density and reduced dry eye symptoms. Without ocular surface management, goblet cell density and dry eye symptoms after LASIK were similar to or worse than after PRK.

Dry eye: an update on clinical diagnosis, management and promising new treatments

Dry eye conditions are prevalent with one in four to five patients presenting to eye care practitioners having dry eye signs and/or symptoms. An intimate relationship exists between the ocular surface and the tear film. The cycle of tear film instability and ocular surface damage characteristic of dry eye conditions suggests that dry eye represents a dysfunction of an integrated ocular surface‐lacrimal gland unit. Therefore, dry eye is a multifactorial condition and an approach based on clinical subtypes is required for diagnosis and management. There is increasing evidence that inflammation is a contributing and exacerbating factor in dry eye conditions and anti‐inflammatory or immunomodulatory therapy for chronic dry eye conditions may facilitate ocular surface healing. Other promising new treatments for dry eye include new generation artificial tear polymers and preservative systems, secretagogues, topical androgen supplements and surgical techniques for ocular surface reconstruction.

Effect of antibacterial honey on the ocular flora in tear deficiency and meibomian gland disease.

Purpose: To assess for differences in the ocular flora of patients with dry eye caused by tear deficiency and/or meibomian gland disease and to assess the effect of antibacterial honey on the ocular flora in these forms of dry eye. Methods: In this prospective, open-label pilot study, bacteria isolated from the eyelid margin and conjunctiva were identified and quantified before and at 1 and 3 months after initiation of treatment with topical application of antibacterial honey 3 times daily. Subjects had non-Sjogren tear deficiency (n = 20), Sjogren syndrome tear deficiency (n = 11), meibomian gland disease (n = 15), and non-Sjogren tear deficiency with meibomian gland disease (n = 20), and there were 18 non-dry eye subjects. Results: The total colony-forming units (CFUs) isolated from each of the dry eye subgroups before antibacterial honey use was significantly greater than the total CFU isolated from the non-dry eye group. Antibacterial honey use significantly reduced total CFUs for the eyelids and the conjunctiva of dry eye subjects from baseline at month 1 (eyelids: P = 0.0177, conjunctiva: P = 0.0022) and month 3 (eyelids: P < 0.0001, conjunctiva: P < 0.0001). At month 3, there were reductions in total CFUs for all dry eye subgroups such that the CFUs were not significantly different from those of the non-dry eye group. Conclusion: From these results, there is sufficient preliminary data to warrant further study of the effects of antibacterial honey in chronic ocular surface diseases.

Management of the Ocular Surface and Tear Film Before, During, and After Laser in situ Keratomileusis

PURPOSE To identify evidence-based, best practice strategies for managing the ocular surface and tear film before, during, and after laser in situ keratomileusis (LASIK). METHODS After a comprehensive review of relevant published literature, evidence-based recommendations for best practice management strategies are presented. RESULTS Symptoms of ocular irritation and signs of dysfunction of the integrated lacrimal gland/ocular surface functional gland unit are common before and after LASIK. The status of the ocular surface and tear film before LASIK can impact surgical outcomes in terms of potential complications during and after surgery, refractive outcome, optical quality, patient satisfaction, and the severity and duration of dry eye after LASIK. Before LASIK, the health of the ocular surface should be optimized and patients selected appropriately. Dry eye before surgery and female gender are risk factors for developing chronic dry eye after LASIK. Management of the ocular surface during LASIK can minimize ocular surface damage and the risk of adverse outcomes. Long-term management of the tear film and ocular surface after LASIK can reduce the severity and duration of dry eye symptoms and signs. CONCLUSIONS Strategies to manage the integrated ocular surface/lacrimal gland functional unit before, during, and after LASIK can optimize outcomes. As problems with the ocular surface and tear film are relatively common, attention should focus on the use and improvement of evidence-based management strategies.

Effect of carmellose-based artificial tears on the ocular surface in eyes after laser in situ keratomileusis.

BACKGROUND Strategies to minimize intraoperative ocular surface disturbance and accelerate postoperative ocular surface recovery are an important consideration to the surgeon. METHODS Eighteen eyes of 10 patients were randomized to receive intraoperative and postoperative non-preserved balanced salt solution or non-preserved carboxymethylcellulose-based (carmellose) artificial tears. Presence and severity of McMonnies dry eye symptom survey score primary dry eye symptoms, fluorescein break-up time, and rose bengal staining were graded preoperatively and at 1 day, 1 week and 1 month postoperatively. Conjunctival impression cytology of the perilimbal conjunctiva was performed 1 month after surgery to determine goblet cell density. RESULTS McMonnies dry eye symptoms were reported more frequently for the balanced salt solution group at 1 day, 1 week, and 1 month after surgery. Fluorescein break-up time was significantly greater in the carmellose-based group at 1 day (P < .01), 1 week (P = .04), and 1 month (P < .01) after surgery. The rose bengal staining score was significantly greater at 1 day (P < .01) and 1 week (P < .01) postoperatively for the balanced salt solution group. Mean goblet cell density for the carmellose-based group at 1 month postoperatively was significantly greater than that for the balanced salt solution group (P < .01). CONCLUSIONS Postoperative and intraoperative use of carmellose-based artificial tears resulted in significantly more rapid recovery of the ocular surface after LASIK when compared to balanced salt solution.