Thursday, January 7, 2010

Wow! I almost woke up for this one. Look forward to seeing more on this topic. Sounds like it's wide open for new discoveries that could be... very very relevant.

The role of microbial flora on the ocular surface.
Curr Opin Allergy Clin Immunol. 2009 Oct;9(5):466-70.
Miller D, Iovieno A.

Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami, Florida 33101, USA.
PURPOSE OF REVIEW: Presence and interplay of microbial flora at the ocular surface reveal dynamic and evolving interactions with implications for both ocular surface health and disease. Data in this area are scarce or non-existent. The purpose of this review is to provide a snapshot of new and emerging developments in this area over the last 12 months.

RECENT FINDINGS: Recent findings signal potential roles for ocular surface microbial flora in both the preservation and extension of ocular surface health and in the initiation of new or escalation of common surface disorders. Contributions range from priming surface epithelial immune cells to regulating mucin composition and production. Other findings explore the emergent role of ocular microbial flora cross talk with pattern recognition receptors to protect and strengthen local and adaptive mucosal immunity while preserving vision.

SUMMARY: Deciphering the functional role of microbial communities at the ocular surface could bring new insights into and clarify the epidemiology and pathology of ocular surface dynamics in health and disease

Abstract: More technical stuff (yawn)

Sorry I'm so ho-hum on this. Some days I really dig these types of studies and other days... I don't. I love mucins and if anything could wake me up that should but somehow just not the right chemistry for me today. However, knowing I'll want to see it again (even if no one else does) I couldn't possibly omit these sorts of things from the blog.

Effect of pro-inflammatory mediators on membrane-associated mucins expressed by human ocular surface epithelial cells.
Exp Eye Res. 2009 Dec 28. [Epub ahead of print]
Albertsmeyer AC, Kakkassery V, Spurr-Michaud S, Beeks O, Gipson IK.
Schepens Eye Research Institute, Harvard Medical School, 20 Staniford Street Boston, MA 02114, USA.

Membrane-associated mucins are altered on the ocular surface in non-Sjögren's dry eye. This study sought to determine if inflammatory mediators, present in tears of dry eye patients, regulate membrane-associated mucins MUC1 and -16 at the level of gene expression, protein biosynthesis and/or ectodomain release. A human corneal limbal epithelial cell line (HCLE), which produces membrane-associated mucins, was used. Cells were treated with interleukin (IL)-6, -8, or -17, tumor necrosis factor-alpha (TNF-alpha), and Interferon-gamma (IFN-gamma), or a combination of TNF-alpha and IFN-gamma, or IFN-gamma and IL-17, for 1, 6, 24, or 48 h. Presence of receptors for these mediators was verified by RT-PCR. Effects of the cytokines on expression levels of MUC1 and -16 were determined by real-time PCR, and on mucin protein biosynthesis and ectodomain release in cell lysates and culture media, respectively, by immunoblot analysis. TNF-alpha and IFN-gamma each significantly induced MUC1 expression, cellular protein content and ectodomain release over time. Combined treatment with the two cytokines was not additive. By comparison, one of the inflammatory mediators, IFN-gamma, affected all three parameters-gene expression, cellular protein, and ectodomain release-for MUC16. Combined treatment with TNF-alpha and IFN-gamma showed effects similar to IFN-gamma alone, except that ectodomain release followed that of TNF-alpha, which induced MUC16 ectodomain release. In conclusion, inflammatory mediators present in tears of dry eye patients can affect MUC1 and -16 on corneal epithelial cells and may be responsible for alterations of surface mucins in dry eye. Copyright © 2009. Published by Elsevier Ltd.

Abstract: Omega 3 EFA and dry eye

Nothing in the abstract that we don't all already know, but if you're looking for a review of current literature on Omega 3s and dry eye, it might be worth getting the whole article.

Essential fatty acids for dry eye: A review.
Cont Lens Anterior Eye. 2009 Dec 21. [Epub ahead of print]
Roncone M, Bartlett H, Eperjesi F.
Ophthalmic Research Group, School of Life & Health Sciences, Aston University, Birmingham B4 7ET, UK.

PURPOSE: Dry eye is a common complaint often encountered in optometric practice. However, it is a difficult condition to treat as clinical signs do not always correlate with patient symptoms. Essential fatty acids (EFA), particularly omega-3 EFA, may be effective in dealing with the underlying causes.

METHODS: A literature review was carried out on the PubMed, ScienceDirect and Ovid databases. Searches included keywords such as 'dry eye', 'essential fatty acids' and 'nutrition' to find articles relating to the treatment of dry eye syndrome (DES) with omega-3 EFAs.

RESULTS: Omega-3 and -6 EFAs need to be consumed together within a reasonable ratio to be effective. Currently, typical diets in developed countries lack omega-3 EFA and this results in an overexposure to omega-6. Omega-3 supplementation has an anti-inflammatory effect, inhibiting creation of omega-6 prostaglandin precursors. Omega-3 EFAs also demonstrate anti-inflammatory action in the lacrimal gland preventing apoptosis of the secretory epithelial cells. Supplementation clears meibomitis, allowing a thinner, more elastic lipid layer to protect the tear film and cornea. CONCLUSION: Dietary supplementation of omega-3 EFA has already proven to be effective in coronary heart disease and arthritis. Safety is not a concern as it works synergistically with omega-6 in the body. Evidence suggests that supplementation with omega-3 EFA may be beneficial in the treatment and prevention of DES. Copyright © 2009 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Device news: Prototype for an interesting new kind of plug

I must confess, catching up on med lit has rarely been as boring as it was today.

Thankfully, towards the bottom of my stack was something actually interesting: An idea for a punctal plug that also delivers a drug to the eye. Fascinating. Sounds like they have a long way to go in really successfully implementing it. Hence the press release scouting for investment dollars.

Punctal Plugs Take Control of Drug Release
Medical Device Link

The use of punctal plugs to treat dry eye patients isn’t new, but a University of Florida (Gainesville) prototype could offer a much-needed improvement.

“It is estimated that 10–30% of people suffer from the condition known as dry eyes,” according to a university press release. Usually caused by a lack of tears on the eye surface, the condition can lead to blindness.

Commercial punctal plugs treat dry eyes by reducing tear drainage from the eyes to the nose, which leads to an increase in tear volume. Punctal plugs developed at the University of Florida block tear drainage and also deliver dry-eye medication, thus providing dual treatment approaches from a single device. The reduced tear drainage improves the drug residence time in tears, resulting in increased efficacy and reduced side effects. The prototype also improves the drug-delivery process, enabling better control of release profiles than conventional plugs, says Anuj Chauhan, PhD, associate professor in the department of chemical engineering.

Chauhan’s plug design (see Figure 1) includes a drug-filled cylindrical core surrounded by an impermeable shell that covers about 50% of the core. The uncovered part is directed toward the eyes. To ensure a snug fit, the outer diameter of the shell matches the inner diameter of the canaliculus.

“The key difference between this design and all other designs is that the there is some space in between the uncovered core and the canaliculus wall, which will be filled with tears,” Chauhan says. “The drug from the core can diffuse radially out into this space and then diffuse axially out into the tears.” Conventional models lack this space, so the drug must diffuse from the circular cross-section of the plug that is in contact with the tears.

Figure 1. (click to enlarge) The design of the punctal plugs leaves space between the uncovered core and the canaliculus wall.
This design modification creates a larger surface area for the drug to diffuse, thus offering better control of drug-release profiles. This characteristic makes it possible to obtain zero-order profiles without any initial burst. It also makes the release profiles less susceptible to reduced drug release caused by protein binding to the plug. According to Chauhan, another advantage is that the plug “has no burst release, which can arise in designs with shell covering the entire plug due to possible leakage from the space in between the shell and the core.”

The plugs are made from hydroxyl methyl methacrylate, a biocompatible material commonly found in ophthalmic applications, and the shell is made from silicone-based materials. The biocompatible material choice means that the plugs can be absorbed into a patient’s body instead of being removed.

Chauhan says that his prototypes currently release dry-eye drugs at a rate of about 3 μg/day, which is therapeutically effective for 45 days. Using an applicator, the plugs can be inserted into a patient’s upper punctum, lower punctum, or both. The permeability of the structure and the release duration can be customized per patient.

Several modifications are planned to further improve the device. Chauhan says that the single core will be replaced with multiple cores and may include “a third layer that surrounds the entire plug to minimize the drug transport into the walls of the canaliculus.” His research team is also exploring the delivery of other medication through the punctal plugs. Heng Zhu, a former student, and Chhavi Gupta, a current student of Chauhan’s, contributed to the invention. A patent is currently pending.

To license the technology, contact University of Florida’s Office of Technology Licensing at

Newsblurb: Well at least they admit it now

Times sure have changed. When I was living in England (2002-5) I never thought I'd live to see the day when Julian Stevens of Moorfields would tell the Times that the early years of doing LASIK were "burn and learn". Gosh. So glad I could be of service in the learning process. What's one pair of corneas more or less after all.

Laser Eye Surgery news

`Potential complications` can arise from laser eye surgery

People must take potential complications into consideration and make an informed decision about whether to get laser eye surgery, according to lifestyle website

Laser eye surgery has come a long way from the early days of the treatment. But despite a great deal of care being taken by surgeries to make it a safe procedure, complications can still arise.

The most common type of laser eye surgery is LASIK, but all forms are carried out by a laser which reshapes the cornea and removes some corneal tissue to change the focussing power of the eye.

Some patients can lose parts of their vision or suffer from conditions such as glare which cannot be corrected. Some may also develop severe dry eye.

In general, most treatments are not completely satisfying in patients who have large refractive errors, the website says, and the treatment is not always thorough enough to completely remove the need for glasses or contact lenses.

Julian Stevens, a surgeon at Moorfields Eye Hospital, told the Times on the 20th anniversary of the treatment, that "to some extent it was burn and learn” in the initial period of laser surgery.

Abstract: If you think you've got it bad... grateful you don't have this. I for one am grateful that I had thirty-plus years of life without dry eye. Starting out life with it is not a good thing.

[The lacrimo-auriculo-dento-digital syndrome (LADD): case report and literature review]
Arq Bras Oftalmol. 2009 Sep-Oct;72(5):715-8.
[Article in Portuguese]
Caluff PR, Silva AL, Mascaro VL, Neustein I.

Universidade Federal do Pará, Belém, PA, Brasil.
Levy-Hollister or lacrimo-auriculo-dento-digital (LADD) syndrome is a rare entity with autossomic dominant inheritance occuring as an isolated form or affecting many family generations. Diagnosis is based on the identification of the lacrimal drainage system abnormalities with reduction or absence of tear production and bone, teeth, salivar glands and outer ear abnormalities. A 13 year-old male patient has been followed at the Hospital Servidor Público Estadual in São Paulo due to dry eye since his first year of life. Due to the occurrence of early ocular manifestations in patients with Levy-Hollister or lacrimo-auriculo-dento-digital syndrome, ophthalmologists must be aware to recognize and control this syndrome.

Abstract: Carmellose sodium, sodium hyaluronate

I would love to get some comments on this one from Those Who Know. First off I don't really know anything about the carmellose drop. Secondly, with HLA drops, it's always a little tricky because (as I first learned with Dr. Holly's drops) just the name & concentration don't always tell you what you need to know. What is Lubristil and how does it compare to other HLA drops on the market in Europe and the US?

Comparative Analysis of Carmellose 0.5% Versus Hyaluronate 0.15% in Dry Eye: A Flow Cytometric Study.
Cornea. 2009 Dec 16. [Epub ahead of print]
Sanchez MA, Torralbo-Jimenez P, Giron N, de la Heras B, Herrero Vanrell R, Arriola-Villalobos P, Diaz-Valle D, Alvarez-Barrientos A, Benitez-Del-Castillo JM.

PURPOSE:: To compare the effects of Viscofresh 0.5% (carmellose sodium 0. 5%) versus Lubristil (sodium hyaluronate 0.15%) in dry eye syndrome and to study the influence of these two treatments on the expression of various inflammatory markers by flow cytometry in impression cytology specimens.

METHODS:: In this randomized, masked-observer, parallel group, single-center study, 15 patients with dry eye syndrome were randomized to sodium carmellose 0.5% or sodium hyaluronate 0.15% 1-month treatment after a 1-week washout period. Corneal staining with flurescein, breakup time, Schirmer 1 test with anesthesia (Jones test), and tear clearance were assessed. Besides, conjunctival impression cytology was performed to investigate inflammatory markers (CD3, CD11b, and HLA-DR) using flow cytometry.

RESULTS:: Carmellose group shows statistical improvement compared with the hyaluronate group in breakup time, corneal staining, and HLA-DR. The two other inflammatory markers had also a tendency for a decreased expression in both groups, with no statistical significance. There were neither visual acuity loss nor other complications related to treatment.

CONCLUSION:: Both artificial tears improve dry eye signs and symptoms and inflammatory markers expression, with significant better results in carmellose group.

Newsblurb: The war between insurers and medical care

I thought some of you would appreciate this behind-the-scenes description of what eye doctors go through in the daily battles with insurance companies telling them how they can or can't treat their patient. I love that this doctor went to bat for her patient in a big way to get her Restasis (which was helping her but was suddenly yanked by the insurer) covered again. Hope she also got her into some tranquileyes or something other barrier product considering those night symptoms.

Scrubbing In: Insurers' decisions on drugs mystify
Philadelphia Inquirer

My patient, a 59-year-old Cambodian woman, has amassed one of those thick charts, the size of a small coffee-table book. It means she's a veteran of our cornea clinic.

At her most recent appointment, she looked unhappy. "My eyes burn and itch," she said through her son who translated. "I can't sleep at night."

Ever since her insurer decided not to cover Restasis, a drop for severe dry eyes, her symptoms had returned. The decision seemed odd since the drug had been approved several times before.

No one ever taught me this in medical school, but formularies - the insurer's preferred list of drugs - are often the final say when practicing medicine. You can study hard and read the current journals to know the latest options, but if an insurer doesn't cover it, you're out of luck.

A severe case of dry eye can be devastating. I've had patients apply for disability from their dryness. They have light sensitivity and burning to the point that they cannot work.

My patient has tried various concoctions of drops and ointments over the years.

She finally got some relief recently when we started Restasis, a topical anti-inflammatory drop.

So why would her insurer suddenly stop covering her drops, making her pay about $700 for a six-month supply? My attending doctor suggested that I re-petition. And so I did.

I filled out the sheet pretty much as my colleague had a few months before.

"Failed other therapies," I wrote. Then I added: "Since being off Restasis, can't sleep at night."

I faxed it off and kept my fingers crossed.

Meanwhile, to get a better shot at approval, I thought I should call the insurer. Of course I knew better.

Clinic was busy as usual. Plus, I recalled an attempt I had made a few months earlier.

A patient who had a corneal transplant was tapering off his steroids. He had gone from a high-potency steroid many times a day to once a day and now was ready for an even less potent one.

But we had to keep him on the stronger one - which he didn't need - because his insurer would not cover the costlier low-dose steroid. We thought our argument was sound: Stronger steroids make cataracts and glaucoma more likely.

So I was angry when they denied our request for his "pre-authorization." I called the insurer and got lost in a phone maze a couple of times. Then, I kept pressing 0 and somehow got to a human being. (This is why some doctors' offices hire teams of employees to deal only with insurance issues.)

"May I speak to the person making decisions about what to cover for ophthalmologic therapies?" I asked.

The operator told me that I needed to fill out a "pre-authorization" form.

"But surely, there must be someone I could explain this to over the phone," I said.

Back came what sounded like a robotic response. "A clinical pharmacist will get back to you within 48 hours by fax."

I often wonder who makes up these lists for what is and isn't covered.

Yes, I understand that the correct drug is important in a world with limited resources. And obviously pharmaceutical companies are trying to make a profit, taking advantage of the fact that in many cases they have a 17-year patent on the medicine and can charge whatever they want.

But some coverage decisions are puzzling.

Why pay for only one pair of glasses for children per year? Isn't it a certainty that they break them? Why do most patients have to pay cash for rigid contact lenses but insurance will cover corneal transplants?

Doesn't this skew the decision-making toward a riskier procedure?

And it's a mistake to think that existing public plans will solve this problem, as some suggest in the health debate.

This older patient's plan was actually a Medicaid plan run through a local HMO. It might be better to let patients pay a small percentage of the total and let them decide if they can swing the more expensive drug.

Meanwhile, perplexities abound. Why did the HMO approve a drop for several months, and then suddenly unapprove it?

I wonder if insurance and pharmacy execs are cutting secret deals so that a plan will have a financial reason to cover one drug over another.

Or maybe there's a technical advisory committee of highly trained scientists who weigh the pros and cons of each option, and then take into account the costs.

Or maybe it just depends on what kind of day the approver is having. I'll never know. The only thing we're allowed to do is fax them.

As for my patient with dry eyes, the fax finally arrived. "Your patient has been approved for Restasis for 6 months. Please inform them."

I celebrated the good news with her daughter, who would translate it for her. And now she's back in business - for six months at least.

Abstract: Another technical one about T cells

Programmed Death-Ligand 1 (PD-L1) Regulates T cell Chemotaxis in Dry Eye-Associated Corneal Inflammation.
Invest Ophthalmol Vis Sci. 2009 Dec 17. [Epub ahead of print]
El Annan J, Goyal S, Zhang Q, Freeman G, Sharpe A, Dana R.

Ophthalmology, Harvard Medical School, Schepens Eye Research Institute and Massachusetts Eye and Ear Infirmary, Boston, United States.
Purpose: Given that dry eye disease (DED) is associated with T cell-mediated inflammation of the ocular surface, and PD-L1 is an important 'negative' or inhibitory regulator of immune responses that is constitutively expressed at high levels by corneal epithelial cells, we studied the expression and function of PD-L1 in DED.

Methods: Dry eye was induced in untreated wild-type mice, PD-L1-/- mice, and wild-type mice treated with anti-PD-L1 antibody by exposing these mice to a desiccating environment in the controlled environment chamber (CEC) modified with subcutaneous administration of scopolamine. Real-time PCR was used to quantify the expression of chemokine gene transcript levels of multiple CC and CXC chemokine ligands and receptors. Epifluorescent microscopy was used to evaluate corneal infiltration of CD3+ T cells after immunohistochemical staining.

Results: The increased expression of specific chemokine ligands and receptors in PD-L1-/- corneas of normal mice is associated with significant increase in T cell homing into these corneas. Similar, and more enhanced increases in T cell infiltration were observed in PD-L1-/-DED mice or DED mice treated with anti-PD-L1 antibody as compared to controls. In addition, we found a significantly decreased expression of PD-L1 by corneal epithelial cells in DED and a significantly increased corneal fluorescein staining score with PD-L1 functional blockade using anti-PD-L1 antibody.

Conclusion: Downregulation of corneal epithelial PD-L1 amplifies dry eye-associated corneal inflammation and epitheliopathy by increasing the expression of chemokine ligands and receptors that promote T cell homing to the ocular surface.

Abstract: About something that might improve mucin secretion

Effects of DA-6034, a flavonoid derivative, on mucin-like glycoprotein and ocular surface integrity in a rabbit model.
Arzneimittelforschung. 2009;59(10):498-503.
Choi SM, Seo MJ, Lee YG, Lee MJ, Jeon HJ, Kang KK, Ahn BO, Yoo M.
Research Laboratories, Dong-A Pharmaceutical Company, Kyunggi-do, Korea.

This study was designed to assess whether DA-6034 (7-carboxymethyloxy-3',4',5-trimethoxy flavone monohydrate), a new synthetic derivative of eupatilin, increases secretion of mucin-like glycoprotein and some mucins species in conjunctiva and cornea, and contributes to the preservation of ocular surface integrity. Human conjunctival and corneal epithelial cells were incubated with DA-6034 (1-250 microM). To investigate mucin secreting activity more directly, isolated rat conjunctival goblet cells were also used. Corneal protection was investigated using a desiccation-induced rabbit model of dry eye syndrome. It was found that DA-6034 increased mucin-like glycoprotein levels of both conjunctival and corneal epithelial cells at concentrations above 100 microM. Using human conjunctival epithelial cells, it was demonstrated that treatment with DA-6034 (200 microM) significantly increased production of some mucins species including MUC1, MUC2, MUC4, MUC5AC, MUC5B, and MUC16. DA-6034 also significantly increased MUC5AC production from conjunctival goblet cells isolated from rats. In the rabbit desiccation model, an ophthalmic suspension containing 3% DA-6034 significantly reduced corneal damage induced by desiccation. These results suggest that DA-6034 is a good candidate for treatment of dry eye through maintaining ocular surface integrity, which might be related to mucin secretion.

Abstract: Technical stuff about JNK2 protein

Essential role for c-Jun N-terminal kinase 2 in corneal epithelial response to desiccating stress.
Arch Ophthalmol. 2009 Dec;127(12):1625-31.
De Paiva CS, Pangelinan SB, Chang E, Yoon KC, Farley WJ, Li DQ, Pflugfelder SC.
Ocular Surface Center, Cullen Eye Institute, Baylor College of Medicine

OBJECTIVE: To investigate the protective effects of c-Jun N-terminal kinase (JNK)-1 and -2 gene knockout (KO) on the corneal epithelial response to desiccating stress.

METHODS: The C57BL/6, JNK1KO, and JNK2KO mice were subjected to desiccating stress (DS) for 5 days. The effects of DS on the corneal epithelium were evaluated by measuring corneal smoothness and permeability. Expression of matrix metalloproteinases (MMP)-1, MMP-9, and cornified envelope protein precursors (small proline-rich protein [SPRR]-1a, SPRR-2a, and involucrin) in the corneal epithelia was evaluated by immunostaining and real-time polymerase chain reaction. Collagenase and gelatinase activity in corneal sections as measured with in situ fluorescent assays.

RESULTS: The JNK2KO mice had smoother corneal surfaces and less corneal barrier disruption in response to DS than JNK1KO mice and C57BL/6 wild-type control mice. The DS increased levels of MMP-1, MMP-9, SPRR-1a, SPRR-2a, involucrin immunoreactivity, and mRNA transcripts in the corneal epithelium of JNK1KO and C57BL/6 mice, but not in JNK2KO mice. Knockout of JNK2 prevented DS-induced increase in gelatinase and collagenase activity in the cornea.

CONCLUSION: The JNK2 protein appears to have an essential role in desiccation-induced corneal epithelial disease by stimulating production of MMP-1, MMP-9, and cornified envelope precursors. Clinical Relevance The JNK2 protein could be a novel therapeutic target in dry eye disease.

Abstract: What eye doctors think of the dry eye treatment status quo

Summary of how satisfied eye doctors are with their treatments.

Couple of useful gleanings:

1) It may seem to you that your doctor does not understand how much pain you're in or doesn't take you seriously. However, clearly, across the board, ophthalmologists (and this is including the minimally-dry-eye-literate ones, since apparently only 1.53 corneal specialists responded to this - oh and by the way, why did they send it to only 51 of those? hm) know that the treatments they're giving are inadequate. They know you're not happy and they want better treatments too.

2) If you have ever felt like you're the only one out there with this problem... take a look at this. 96% of doctors responding to this survey treat at least 4 People Like You Or Worse every month. Now, given how eye doctors think about corneas, they're probably only counting the people whose corneas are actually visibly in bad shape. If they have some of those, they probably have even more of the classic "I hurt a lot worse than I look under a slitlamp" patients. You are not alone. Anything but.

Ophthalmologist Perceptions Regarding Treatment of Moderate-to-Severe Dry Eye: Results of a Physician Survey.
Eye Contact Lens.. [Epub ahead of print]
Asbell PA, Spiegel S.
From the Department of Ophthalmology (P.A.A.), Mount Sinai School of Medicine, New York, NY; and Advanstar Communications (S.S.), New York, NY.

PURPOSE:: To understand ophthalmologists' current perceptions and treatment of patients with moderate-to-severe dry eye disease (DED).

SETTING:: Online survey.

METHODS:: The online survey was sent to 7,882 ophthalmologists, including 51 corneal specialists, throughout the United States from October 9 to 21, 2008. The response rate was 3.1% (n = 245), typical for this type of survey. Only ophthalmologists who treated four or more moderate-to-severe DED patients per month (235 of 245 [96%]) were asked to complete the survey.

RESULTS:: Ninety-four percent of respondents agreed that more treatment options are needed for moderate-to-severe DED. Corneal specialists were more likely to strongly agree (63%) than general ophthalmologists (54%). Only 33% overall felt that current therapies were extremely or very effective for moderate DED and only 5% for severe disease. Ninety-two percent agreed that multiple therapeutic agents are needed to manage moderate-to-severe DED. The respondents prescribed or recommended a mean of 3.2 different treatments (standard deviation = 1.2) for moderate DED patients over the course of a year and 4.9 (standard deviation = 2.2) for patients with severe DED. The most highly ranked goals for treatment of moderate-to-severe DED patients were maintaining and protecting the ocular surface (ranked 1 or 2 x 74%) and lubricating and hydrating the ocular surface (ranked 1 or 2 x 67%). Corneal specialists ranked maintaining and protecting the ocular surface even more highly (ranked 1 or 2 x 82%).

CONCLUSIONS:: Results reflected the difficulty of treating moderate-to-severe DED, the importance of using multiple treatment approaches, the limitations of current treatment options, and the need for additional treatment options.

Abstract: Children, computers and eyes

This caught my eye, and not just because I used to live in Thessaloniki. With dry eye, including severe dry eye, occurring more and more in young people it is certainly high time to be looking into the long term effects of things people start doing as kids that affect the ocular surfaces, including contacts and computer use.

Impact of computer use on children's vision.
Hippokratia. 2009 Oct;13(4):230-1.
Kozeis N.
Paediatric Eye Unit, Eye Dept, Hippokratio Hospital, Thessaloniki, Greece.

Today, millions of children use computers on a daily basis. Extensive viewing of the computer screen can lead to eye discomfort, fatigue, blurred vision and headaches, dry eyes and other symptoms of eyestrain. These symptoms may be caused by poor lighting, glare, an improper work station set-up, vision problems of which the person was not previously aware, or a combination of these factors. Children can experience many of the same symptoms related to computer use as adults. However, some unique aspects of how children use computers may make them more susceptible than adults to the development of these problems. In this study, the most common eye symptoms related to computer use in childhood, the possible causes and ways to avoid them are reviewed.