Thursday, October 14, 2010

Abstract: Dry eye and over-tearing

This is really rather interesting. You've got a whole bunch of people who have been referred to the oculoplasts (specialists that cut up eyelids, among other things) because of excess tearing, presumably so referred on the assumption that the patients' tear drains (nasolacrimal ducts) are obstructed - but in nearly half the cases, it was dry eye causing the tearing.

Who was referring all these people? This really underscores the need for education about excess reflex tearing as a dry eye symptom. It's understandable that PATIENTS don't realize on their own that wet eyes can be caused by dry eyes (it's not a little counterintuitive until you understand the mechanism), but some GPs, optometrists and ophthalmologists may need some reminding about this as well.

Etiology of Tearing: A Retrospective Analysis of Referrals to a Tertiary Care Oculoplastics Practice.
Ophthal Plast Reconstr Surg. 2010 Oct 11. [Epub ahead of print]
Mainville N, Jordan DR.
Department of Ophthalmology, University of Ottawa Eye Institute and The Ottawa Hospital, Ottawa, Ontario, Canada.

PURPOSE: To determine the etiology of tearing among referrals to a tertiary care ophthalmology practice specializing in oculoplastics.

METHODS: A retrospective chart review was conducted of 150 consecutive referrals to our practice for tearing. The main diagnosis was noted in all cases as well as treatment offered and response to therapy. An anatomical approach was used to classify the tearing etiology. The categories included the following: dry eye with reflex tearing, tear hypersecretion, ocular surface disease (e.g., pterygium, pinguecula), lid abnormalities (e.g., entropion, ectropion), upper lacrimal system (e.g., punctal stenosis, canalicular block), and lower lacrimal system (e.g., dacryocystitis, dacryostenosis, nasolacrimal duct obstruction).

RESULTS: Review of the charts of 150 consecutive pts referred for tearing revealed that although the most common etiology was obstruction of the nasolacrimal system, dry eye with reflex tearing was almost as common. Specifically, 48.7% (n = 73) had a blockage of the lacrimal system (8% [n = 12] upper system, 40.7 [n = 61] lower system), 40% (n = 60) were felt to have dry eye with reflex tearing, 6.7% (n = 10 patients) had a lid abnormality, 1.3% (n = 2 patients) had lacrimal hypersecretion, 0.7% (n = 1 patient) had ocular surface disease, and 2.7% (n = 4 patients) had a normal lacrimal system on exam.

CONCLUSIONS: Our retrospective review of a series of patients referred to our practice for tearing revealed a significant proportion of patients whose tearing etiology was other than a nasolacrimal duct obstruction. Of particular interest is the fact that 40% of patients had dry eye with reflex tearing, and the majority of these improved with lubrication. These patients were all identified by performing a Schirmer test to quantify the basal tear production. We believe that the Schirmer test is a useful diagnostic tool in assessing patients with tearing and ensuring that the appropriate management approach is undertaken.

New drops: Systane Balance officially launched

Another drop with a phospholipid.

Alcon Introduces New Systane(R) BALANCE Lubricant Eye Drops for Dry Eye Patients with Meibomian Gland Dysfunction

HUENENBERG, Switzerland, Oct 11, 2010 (BUSINESS WIRE) --

Alcon, Inc. (NYSE: ACL), the world's leader in eye care, announced the launch of Systane(R) BALANCE Lubricant Eye Drops, the newest lubricant eye drop in the Systane(R) family of products. Patients with Meibomian Gland Dysfunction (MGD) are unable to adequately prevent the evaporation of tears, resulting in dry eye symptoms. Systane(R) BALANCE is a scientifically engineered product that contains HP Guar, borate, sorbitol, propylene glycol and Alcon's exclusive LipiTech(TM) System, a unique emulsion technology of mineral oil and an anionic phospholipid. Systane(R) BALANCE is designed to restore the lipid layer and the natural tear film to allow for relief of dry eye symptoms.

"We are dedicated to applying scientific rigor to discover treatments for chronic conditions such as dry eye. Meibomian Gland Dysfunction is a significant cause of dry eye symptoms and now patients who suffer from dry eye associated with MGD can use Systane(R) BALANCE to restore their lipid layer, re-establish their natural tear film and maintain their tear film stability," said Sabri Markabi, M.D., Alcon's chief medical officer and senior vice president of Research and Development.

News: Laser center turns dry eye center

Most of you know my opinions well enough that I can safely leave all the bloviating, pontificating, sermonizing and anathematizing to your imaginations.

NVISION Laser Eye Centers Introduces Its First New Service Since Changing Its Name From TLC Laser Eye Centers

NEWPORT BEACH, CA, Oct 11, 2010 (MARKETWIRE via COMTEX) -- NVISION Laser Eye Centers, formerly part of TLC Laser Eye Centers, is introducing its first new service since changing its name last month.

"If you're one of 22 million people nationwide who suffer daily from dry eyes, the Dry Eye Clinic at our eight NVISON Laser Eye Centers throughout Southern California can offer you comfort and relief with a variety of treatment options," said Dr. Tom Tooma, the Medical Director for NVISION Laser Eye Centers, formerly part of TLC Laser Eye Centers, and renowned eye surgeon who has performed more than 100,000 vision correction procedures.

People who suffer from dry eyes include those who:

-- Wear contact lenses, especially for prolonged periods of time;
-- Are taking medications such as antihistamines or birth control pills;
-- Are over 50, especially women going through menopause;
-- Have specific diseases such as Sjogren's Syndrome, rheumatoid
arthritis and collagen vascular disease;
-- Have eyelids that don't close properly due to structural
-- Or live in dry climates.

If you suffer from dry eyes, you may experience:

-- Burning/Stinging
-- Itchiness
-- Light sensitivity
-- Grittiness/scratchiness
-- Redness of the eye/lid margin areas
-- Blurred vision

NVISON Laser Eye Centers offers both diagnosis and treatment of a variety of dry eye conditions:

Device news: TearLab osmolarity test making strides...

Medicare to Reimburse for TearLab Test
San Diego Business Journal
11 October 2010

San Diego-based TearLab Corp., which is developing therapies for dry eye disease, announced that the Committee for Medicare and Medicaid Services on Oct. 8 published a proposed reimbursement rate for the company’s osmolarity test. Starting in January, the government will reimburse doctors for the test at $24.01 per eye.

Reimbursement by CMS will only be available for doctor’s offices that have a moderate/complex clinical laboratory improvement amendments certificate until TearLab receives CLIA waiver categorization from the Food and Drug Administration. This waiver is currently under review by the FDA.

Osmolarity, or the measurement of salt content in a patient’s eyes, is the accepted standard for objectively diagnosing dry eye disease.

And while we're on the subject:

TearLab Announces Issuance of Core U.S. Patent
October 13 - Wall Street Journal

SAN DIEGO, Oct 13, 2010 (GlobeNewswire via COMTEX) -- TearLab Corporation (TEAR 2.85, -0.02, -0.70%) today announced that it has been granted U.S. Patent No. 7,810,380, entitled "Systems and methods for collecting tear film and measuring tear film osmolarity." This patent provides the company with broad and blocking intellectual property regarding the measurement of genetic and protein biomarkers within the tear film.

The patent, which will expire in 2029, allows TearLab to build upon its non-invasive tear collection platform to explore biomarkers across a wide range of disease states. This includes, but is not limited to, the Company's initial commercial target of Dry Eye Disease.

Abstract: Salivary gland transplantation

I'd like to know how many of the "10 eyes with cicatrizing conjunctivitis and a failed submandibular gland transplantation or no submandibular gland transplantation" were the former. And what "some ocular surface parameters" are. And how many of the patients would do it all over again.

This kind of surgery gives me the willies. I can't imagine why you would do something so invasive (and, apparently, risky) without first trying BOSP.

Long-Term Follow-up after Submandibular Gland Transplantation in Severe Dry Eyes Secondary to Cicatrizing Conjunctivitis.
Am J Ophthalmol. 2010 Oct 2. [Epub ahead of print]
Borrelli M, Schröder C, Dart JK, Collin JR, Sieg P, Cree IA, Matheson MA, Tiffany JM, Proctor G, van Best J, Hyde N, Geerling G.
Centro Grandi Apparecchiature, Seconda Universita degli Studi di Napoli, Napoli, Italy; Department of Ophthalmology, University of Würzburg, Würzburg, Germany.

PURPOSE: To evaluate the long-term results of autologous submandibular gland transplantation in eyes with cicatrizing conjunctivitis and to determine biomechanical and biochemical features of the resulting salivary tear film.

DESIGN: Prospective, observational case series.

METHODS: Fifteen eyes with cicatrizing conjunctivitis with a viable autologous submandibular gland transplantation were compared with 10 eyes with cicatrizing conjunctivitis and a failed submandibular gland transplantation or no submandibular gland transplantation. Best-corrected visual acuity, frequency of tear substitute instillation, severity of dry eye discomfort, lid margin erythema, conjunctival hyperemia, corneal epithelial edema, tear film break-up time, Schirmer test results, and corneal fluorescein and conjunctival Rose Bengal staining were evaluated. In a subgroup central corneal thickness and sensitivity, corneal epithelial barrier function, conjunctival and lid margin flora, and conjunctival impression cytologic analysis results were evaluated. In 3 patients, preoperative and postoperative tear samples were analyzed for viscosity, surface tension, and presence of mucins.

RESULTS: Submandibular gland autotransplantation resulted in long-term improvement of subjective, objective, and some ocular surface parameters. Salivary mucins were detectable in salivary tears after submandibular gland transplantation. The viscosity of salivary tears was more similar to normal saliva and the surface tension was intermediate between the 2 original secretions.

CONCLUSIONS: Submandibular gland autotransplantation provides long-term relief from pain and reduces the need for frequent installation of lubricants.

Abstract: Sensor for imaging tear film and lipid layer

Simultaneous examination of tear film break-up and the lipid layer of the human eye: A novel sensor design (Part 1).
Z Med Phys. 2010 Sep 28. [Epub ahead of print]
Arnold S, Walter A, Eppig T, Bruenner H, Langenbucher A.
Medical Optics at the Institute of Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany; Erlangen Graduate School in Advanced Optical Technologies (SAOT), University of Erlangen-Nuremberg, Erlangen, Germany.

This article presents a non-invasive sensor setup for objective analysis of the pre-corneal human tear-film involving a time-resolved videokeratoscopy and simultaneous imaging of the lipid layer of the tear-film by a second CMOS-camera. This paper describes in detail the mechanical and optical design of the sensor setup, the realization of the entire illumination component with an integrated Placido grid projection, and the calculation of the image formation using the Placido grid. This concept is demonstrated here with a test subject in the full inter-blink period. All images were taken under physiological conditions. The sensor can assist the ophthalmologist in diagnosing Dry-Eye Syndrome. Results and other potential applications are discussed.

Abstract: Long term dry eye outcomes with cGVHD

Tempting but difficult to assign any significance to positive results when you don't know what happened to 82% of the patients.

Long-term Clinical Course of Dry Eye in Patients With Chronic Graft-Versus-Host Disease Referred for Eye Examination.
Cornea. 2010 Sep 28. [Epub ahead of print]
Sáles CS, Johnston LJ, Ta CN.
From the Departments of *Ophthalmology; and †Medicine, Division of Blood and Marrow Transplantation, Stanford University Medical Center, Palo Alto, CA.

PURPOSE: To assess the long-term clinical course of dry eye in patients with chronic graft-versus-host disease (cGVHD).

METHODS: A prospective case series of 49 patients with cGVHD was conducted. Complete history and ophthalmic examination were performed at baseline and at 36 months (range, 26-53). All patients received treatment for dry eye.

RESULTS: Of the 49 participants, 18 (37%) had expired at the time of the 3-year eye examination, 11 were lost to follow-up, 11 declined or were unable to attend the final examination, and 9 (18%) completed the study. There was a statistically insignificant improvement in symptoms of dry eye assessed by the ocular surface disease index [start vs. endpoint: 36 ± 22 (range, 4-72) vs. 30 ± 27 (range, 4-86); P = 0.51]. Visual acuity remained stable at approximately 20/20. Lissamine green staining improved and Schirmer test (with anesthetic) worsened, but neither trend was statistically or clinically significant.

CONCLUSIONS: Stable visual acuity, tear production, and lissamine green staining and a statistically insignificant improvement in dry eye symptoms were observed in the 9 participants who completed this 3-year prospective case series of 49 patients with cGVHD. Insofar as these patients represent a minority (18%) of the original cohort, their clinical course may not be generalizable to all patients with cGVHD but may still suggest that this patient population's prognosis could be characterized by stability and excellent vision. Sufficiently powered prospective studies are required to validate these postulates.

Abstract: PF low-dose dexamethasone in chronic dry eye

Preservative-free low-dose dexamethasone for the treatment of chronic ocular surface disease refractory to standard therapy.
Cornea. 2010 Jul;29(7):723-6.
Jonisch J, Steiner A, Udell IJ.
From North Shore-Long Island Jewish Health System, Department of Ophthalmology, Great Neck, NY 11021, USA.

PURPOSE: To evaluate the short-term safety and efficacy of topical preservative-free dexamethasone 0.01% for the treatment of ocular surface disease and/or tearing refractory to conventional treatments.

METHODS: Retrospective chart review of all patients who received topical unpreserved dexamethasone 0.01% (Leiters Pharmacy, San Jose, CA). Follow-up visits were reviewed for subjective responses to the formulation and intraocular pressure. Responses were graded as significant/complete resolution of symptoms (50%-100% improvement), mild (25%-50% improvement), or no improvement.

RESULTS: Thirty-one patients received topical unpreserved dexamethasone 0.01% for the treatment of ocular surface disease. Follow up ranged from 4 to 60 months (average, 11.5 weeks). Twenty patients (65%) reported moderate or complete resolution of ocular symptoms. Seven patients (22%) had mild improvement in their symptoms. Four patients (13%) had no change in ocular symptoms. No patient in our series developed an elevation of intraocular pressure greater than 5 mm Hg above baseline intraocular pressure. No patient developed intraocular pressure greater than 22 mm Hg.

CONCLUSIONS: Topical nonpreserved 0.01% dexamethasone could be an effective therapy for recalcitrant chronic ocular surface disease.

Abstract: Non-invasive tear film surface assessment

Predicting Dry Eye Using Non-invasive Techniques of Tear Film Surface Assessment.
Invest Ophthalmol Vis Sci. 2010 Sep 29. [Epub ahead of print]
Szczesna DH, Alonso-Caneiro D, Iskander DR, Read SA, Collins M.
Institute of Physics, Wroclaw University of Technology, Wroclaw, Poland.

PURPOSE. To measure tear film surface quality in healthy and dry eye subjects using three non-invasive techniques of tear film quality assessment and to establish the ability of these non-invasive techniques to predict dry eye.

METHODS. Thirty four subjects participated in the study, and were classified as dry eye or normal, based on standard clinical assessments. Three non-invasive techniques were applied for measurement of tear film surface quality: dynamic-area high-speed videokeratoscopy (HSV), wavefront sensing (DWS) and lateral shearing interferometry (LSI). The measurements were performed in both natural blinking conditions (NBC) and in suppressed blinking conditions (SBC).

RESULTS. In order to investigate the capability of each method to discriminate dry eye subjects from normal subjects, the receiver operating curve (ROC) was calculated and then the area under the curve (AUC) was extracted. The best result was obtained for the LSI technique (AUC=0.80 in SBC and AUC=0.73 in NBC), which was followed by HSV (AUC=0.72 in SBC and AUC=0.71 in NBC). The best result for DWS was AUC=0.64 obtained for changes in vertical coma in suppressed blinking conditions, while for normal blinking conditions the results were poorer.

CONCLUSIONS. Non-invasive techniques of tear film surface assessment can be used for predicting dry eye and this can be achieved in natural blinking as well as suppressed blinking conditions. In this study, LSI showed the best detection performance, closely followed by the dynamic-area HSV. The wavefront sensing technique was less powerful, particularly in natural blinking conditions.