Monday, December 13, 2010

Abstract: Dry eye from systemic drugs

This is just a very brief abstract but I thought it was encouraging that dry eye was at the top of the list of ocular side effects being looked at in systemic drugs.

Ocular Complications of Systemic Medications.
Am J Med Sci. 2010 Dec 6. [Epub ahead of print]
Blomquist PH.
From the Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas.

Systemic medications can have adverse effects on the eyes that range from dry eye syndrome, keratitis and cataract to blinding complications of toxic retinopathy and optic neuropathy. This review focuses on major drugs with common ocular side effects and highlights more recently recognized associations with systemic medications. Recommendations for ocular monitoring are given for medications with frequent and/or severe adverse ocular effects.

Abstract: Acupuncture (again)

Acupuncture reduces symptoms of dry eye syndrome: a preliminary observational study.
J Altern Complement Med. 2010 Dec;16(12):1291-4.
Jeon JH, Shin MS, Lee MS, Jeong SY, Kang KW, Kim YI, Choi SM.
1 Acupuncture, Moxibustion, and Meridian Research Center, Korea Institute of Oriental Medicine , Daejeon, South Korea .

The aim of this study was to evaluate the effect of acupuncture treatment on dry eye syndrome.

Design: This was a prospective observational study.

Setting: The study was conducted at a clinical evaluation center for acupuncture and moxibustion of the Korean Institute of Oriental Medicine, Republic of Korea.

Subjects: The subjects were patients with dry eye disease (N = 36), defined by Schirmer test scores of <10 mm/5 min and tear film break-up times (BUTs) of <10 seconds.

Treatments: Participants were treated with acupuncture three times per week for 4 weeks. Measure of effectiveness: Schirmer test scores, BUTs, symptom scores, ocular surface disease index (OSDI) scores and dry eye symptom questionnaires were compared before and after treatment to evaluate the efficacy of acupuncture treatment.

Results: After treatment, symptom scores, OSDI scores and the number of dry eye symptoms were all significantly lower (p < 0.0001). Although tear wettings were significantly higher (left: p < 0.0001, right: p = 0.0012), there were no significant differences in BUTs.

Conclusions: This study suggests that acupuncture treatment can effectively relieve the symptoms of dry eye and increase watery secretion.

Abstract: Tobradex vs. Azasite for bleph

Evaluation of clinical efficacy and safety of tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05% compared to azithromycin ophthalmic solution 1% in the treatment of moderate to severe acute blepharitis/blepharoconjunctivitis.
Curr Med Res Opin. 2010 Dec 7. [Epub ahead of print]
Torkildsen GL, Cockrum P, Meier E, Hammonds WM, Silverstein B, Silverstein S.
Andover Eye Associates, Andover, MA, USA.

To evaluate the clinical efficacy and safety of tobramycin/dexamethasone (TobraDex ST * ; 'ST') ophthalmic suspension 0.3%/0.05% compared to azithromycin (Azasite † ) ophthalmic solution (1%) in the treatment of moderate to severe blepharitis/blepharoconjunctivitis.

Research design and methods:
The study was a multicenter, randomized, investigator-masked, and active-controlled, 15-day study. Enrolled in the study were 122 adult subjects (at least 18 years of age) diagnosed with moderate to severe blepharitis/blepharoconjunctivitis, defined by a minimum score of at least '1' for one of the lid signs, one of the conjunctival signs, and one of the symptoms in at least one eye and a minimum global score (total signs and symptoms score) of '5' in the same eye. One group of 61 subjects received ST with instructions to dose 1 drop four times daily (QID) for 14 days. The other group of 61 subjects received azithromycin and dosed with 1 drop twice daily (BID) for 2 days followed by once daily (QD) dosing for 12 days. Visits were conducted at Day 1 (baseline), Day 8 and Day 15. The a priori primary outcome parameter of the study was the seven-item global score defined as the total score of lid margin redness, bulbar conjunctival redness, palpebral conjunctival redness, ocular discharge (0-3 scale), and lid swelling, itchy eyelids, and gritty eyes (0-4 scale). The study utilized standardized, validated photograph control scales developed by Ora, Inc. (Andover, MA).

Clinical trial registration:
The study was registered at under the registry number NCT01102244.

Results: A statistically significant lower mean global score (p = 0.0002) was observed in subjects treated with ST compared to subjects treated with azithromycin at Day 8. No serious adverse events were reported during the course of the study in either group.

Conclusion: ST provides a fast and effective treatment of acute blepharitis compared to azithromycin. Initial therapy with the combination of tobramycin/dexamethasone provides faster inflammation relief than azithromycin for moderate to severe blepharitis/blepharoconjunctivitis.

Abstract: Lotemax buffering Restasis

We needed another study to tell us that Lotemax helps Restasis not to burn?

Topical Loteprednol Pretreatment Reduces Cyclosporine Stinging in Chronic Dry Eye Disease.
J Ocul Pharmacol Ther. 2010 Dec 6. [Epub ahead of print]
Sheppard JD, Scoper SV, Samudre S.
1 Virginia Eye Consultants and the Department of Ophthalmology, Eastern Virginia Medical School , Norfolk, Virginia.

This retrospective, clinical comparative analysis describes differences in clinical signs and symptoms and medication tolerability between those patients who receive topical corticosteroids prior to initiation of topical cyclosporine 0.5% emulsion (tCSA) therapy for chronic dry eye disease (CDED) and those who received tCSA and were not first induced with corticosteroid drops. tCSA is the only approved medication for CDED. Stinging is the most common side effect of tCSA and reason for tCSA discontinuation. This analysis describes an effective pharmacologic means to reduce tCSA stinging and subsequent discontinuation.

Thirty-six consecutive patients were initially treated with loteprednol etabonate (LE) 0.5% (Lotemax; Bausch & Lomb) for a period ranging from 2 to 16 months prior to institution of concomitant tCSA (Restasis™; Allergan). Clinical parameters (fluorescein staining, conjunctival redness, tear meniscus) were compared over a period of 6 months to a second cohort of 36 consecutive patients who were initially prescribed continuous tCSA without concomitant LE pretreatment. Patients in the LE pretreatment group discontinued LE after 3-6 months of concomitant therapy while continuing tCSA therapy.

Of the 36 LE pretreatment patients, only 2 developed significant stinging (5.5%) and 1 discontinued the use of tCSA because of stinging (2.8%). Of the patients without LE pretreatment, 8 developed stinging (22%) and 3 discontinued tCSA as a result (8.3%). The intergroup P value was significant for severe stinging (<0.02) and for tCSA discontinuation because of severe stinging (<0.04). Patients in the LE pretreatment group had no statistically significant differences in preenrollment disease severity or demographics (P range from 0.19 to 0.59) compared with the group without pretreatment.

Topical corticosteroid preparation of the ocular surface in CDED with LE induction therapy may reduce discomfort from subsequent long-term maintenance topical medications, particularly tCSA. This analysis describes a readily available induction and maintenance pharmacologic strategy to reduce tCSA stinging and subsequent discontinuation.

Abstract: Impression cytology and dry eye signs/symptoms

How closely does impression cytology correlate with dry eye signs and symptoms? Not very, apparently.

[Clinical- histological correlation in pacients with dry eye.]
Arch Soc Esp Oftalmol. 2010 Jul;85(7):239-245.
[Article in Spanish]
Morales-Fernández L, Pérez-Álvarez J, García-Catalán R, Benítez-Del-Castillo JM, García-Sánchez J.
Unidad de Superficie ocular, Hospital Clínico San Carlos, Madrid, España.

AIM: It is well known that there is a lack of association between symptoms and signs in patients with dry eye disease. The purpose of this study was to assess if there was any agreement between common dry eye diagnostic tests and to compare them with impression cytology.

METHODS: A total of 40 patients were enrolled in this cases-controls study. The group of cases consisted of 20 patients previously diagnosed with dry eye and the controls were 20 volunteers. The examination included: the quality of life test OSDI, break up time test (BUT), fluorescein staining, Schirmer's test and finally the study of goblet and conjunctival epithelial cells with impression cytology. The Student t and U Mann-Whitney tests were used to evaluate the results, and Spearmańs Rho coefficient to assess their correlation.

RESULTS: Statistical differences were observed between cases and controls Group for all tests (P<0.0001). After assessing the good correlation between BUT, fluorescein staining and Schirmer's test, we studied their association with the impression cytology. The number of isolated goblet cells showed a weak association with the majority of tests, however the grade of metaplasia showed a greater association.

CONCLUSION: Impression cytology is a valuable test in the diagnosis of dry eye. Although the number of goblet cells is not a sufficient diagnostic criterion, its joint assessment with the grade of metaplasia and the other dry eye tests is useful.

Abstract: Gold weight implants for non-facial palsy

Wish they told us how these patients actually felt and what clinical dry eye signs they might have had.

Blink Lagophthalmos and Dry Eye Keratopathy in Patients with Non-facial Palsy: Clinical Features and Management with Upper Eyelid Loading.
Ophthalmology. 2010 Nov 18. [Epub ahead of print]
Patel V, Daya SM, Lake D, Malhotra R.
Corneoplastic Unit, Queen Victoria Hospital, East Grinstead, United Kingdom.

PURPOSE: To evaluate the outcome of using upper eyelid gold weight implantation for patients with non-paralytic lagophthalmos on blink (LOB) only. We highlight the features of incomplete blink and reduced blink rate in patients with non-facial palsy as an exacerbating factor in dry eye keratopathy.

DESIGN: Retrospective, noncomparative case series.

PARTICIPANTS: Twelve patients (21 procedures) who underwent upper eyelid gold weight implantation for non-paralytic LOB only.

METHODS: Retrospective case note review of patients who underwent upper eyelid loading for non-paralytic LOB only over a 5-year period at a single institution.

MAIN OUTCOME MEASURES: Improvement in LOB, gentle and forced closure, increased frequency of blinking (FOB), degree of corneal staining, incidence of epithelial defects or corneal ulcer, improvement in vision, and subjective improvement in ocular discomfort.

RESULTS: Twenty-one procedures in 12 patients. Nine patients underwent bilateral surgery. Mean age was 56 (range, 8-80) years. Median postoperative follow-up was 15 months, and mean follow-up was 20.38±16.61 (6-58) months. Eleven of 12 patients had an improvement in LOB and increased FOB, resulting in improvement of keratopathy and reduced ocular discomfort. One patient developed superior corneal thinning and descemetocele, requiring removal of the gold weight; 1 patient required ptosis surgery; and 1 patient developed a gold allergy and underwent platinum chain exchange.

CONCLUSIONS: We highlight the need to consider incomplete blink and reduced FOB as exacerbating factors for corneal-related disorders, including dry eye. Upper eyelid loading with gold weight implantation is a useful and predictive method of improving exposure-related keratopathy due to LOB in the absence of facial palsy.

FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Abstract: SPHP700-3 (OTC drop)

Don't get excited yet. It's apparently a povidone OTC drop "showed to be safe and effective in mild to moderate dry eye". The same could probably be said of any OTC lubricant drop... No information available yet to tell us what if anything is different here.

A Multicenter, Double-Blind, Parallel Group, Placebo-Controlled Clinical Study to Examine the Safety and Efficacy of T-Clair SPHP700-3 in the Management of Mild to Moderate Dry Eye in Adults.
Cornea. 2010 Nov 17. [Epub ahead of print]
Villani E, Laganovska G, Viola F, Pirondini C, Baumane K, Radecka L, Ratiglia R.

From the *UO Oculistica, Dipartimento di Neuroscienze e Organi di Senso, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Universitá degli Studi di Milano, Milan, Italy; and †Department of Ophthalmology, Stradins University Hospital, Riga, Latvia.

PURPOSE: To study the safety and efficacy of T-Clair SPHP700-3, a new over-the-counter preservative-free formulation, in the management of mild to moderate dry eye in adults.

METHODS: Sixty adult patients with mild to moderate dry eye were consecutively recruited in 2 eye clinics and randomized into 2 groups: treatment and placebo. Signs and symptoms of dry eye were compared along 28 days of treatment.

RESULTS: No adverse events were reported during the study. Symptoms and signs of dry eye showed significant differences between the 2 groups after 2 and 4 weeks of treatment.

CONCLUSIONS: SPHP700-3 preservative-free formulation showed to be safe and effective in mild to moderate dry eye, improving tear film stability, ocular surface lubrification, and patients' symptomatology.

Abstract: Age-related variations of human tear meniscus...

Age-related Variations of Human Tear Meniscus and Diagnosis of Dry Eye With Fourier-domain Anterior Segment Optical Coherence Tomography.
Cornea. 2010 Nov 23. [Epub ahead of print]
Qiu X, Gong L, Sun X, Jin H.
From the *Department of Ophthalmology, Eye Ear Nose and Throat Hospital of Fudan University, Shanghai, China; and †Department of Biostatistics and Social Medicine, School of Public Health, Fudan University, Shanghai, China.

PURPOSE: To determine the age-related variations in the human tear meniscus using Fourier-domain anterior segment optical coherence tomography (FD-ASOCT) and evaluate its application in dry eye screening and diagnosis.

METHODS: One hundred forty-six patients with dry eye and 160 healthy controls were enrolled in this prospective, randomized, case-control study and grouped according to age: group A (0-19 years), group B (20-39 years), group C (40-59 years), and group D (>60 years). Tear meniscus height, tear meniscus depth, and tear meniscus cross-sectional area (TMA) were measured using FD-ASOCT (RTVue-100); corneal fluorescein staining, tear film breakup time, Schirmer I test, and a dry eye questionnaire were also estimated.

RESULTS: Tear meniscus values were significantly correlated with clinical examination results and dry eye syndrome. Mean tear meniscus height, tear meniscus depth, and TMA values of patients with dry eye were significantly lower than those of the controls (P < 0.05). Tear meniscus values were negatively correlated with age in healthy Chinese subjects. Intraindividual variations in optical coherence tomography results were small in each group. Accuracy of dry eye diagnosis by FD-ASOCT was approximately 70%, and the clinical diagnostic critical point became lower with increasing age. Significant differences were observed in the tear meniscus borderline, TMA, and tear transparency between the 2 groups.

CONCLUSIONS: FD-ASOCT provides blur-free imaging and precise measurement of the tear meniscus, which is consistent with clinical examinations. Therefore, FD-ASOCT is expected to become a valuable technique in dry eye screening and diagnosis.

Drug news: Mimetogan's MIM-D3 starting human clinical

Mimetogen Pharmaceuticals Announces Initiation of Phase II Clinical Trial of Novel NGF Mimetic in Patients with Dry Eye

The Vancouver Sun, November 22, 2010

Mimetogen Pharmaceuticals Inc., a clinical-stage biotechnology company focused on developing novel small molecule compounds that mimic the effects of neurotrophins, today announced that it has initiated the first human clinical trial evaluating MIM-D3, a mimetic of nerve growth factor (NGF), in a Phase II clinical trial in patients with moderate to severe dry eye disease. MIM-D3 is a small cyclic peptidomimetic of NGF, a naturally occurring protein in the eye that is responsible for the maintenance of corneal nerves and epithelium, mucin and tear production.

"This is a key development milestone for Mimetogen, as this trial represents the first use of small molecule mimetics of neurotrophins to treat an ocular disease. Encouraging data in animal models of dry eye suggests that the use of neurotrophin mimetics to treat dry eye and other degenerative ocular indications such as glaucoma is an important new approach to treat ocular diseases for which there are currently very limited treatment options, said Garth Cumberlidge, Ph.D., Chief Executive Officer of Mimetogen. "We are excited to have initiated this study, and anticipate receiving data in mid-2011.”

Drug news: Restasis approved in Canada

I know I reported on this before, but at that time there still weren't any news reports about it. Here's one, albeit with a rather inappropriate title:


ORONTO, Nov. 25, 2010 (Canada NewsWire via COMTEX) --
RESTASIS(®)(1) is Now Approved by Health Canada for the Treatment of Dry Eye Disease

Allergan is pleased to announce that Health Canada has approved RESTASIS(®) (cyclosporine) ophthalmic emulsion, 0.05% w/v for the treatment of moderate to moderately severe Dry Eye disease ("Dry Eye"). RESTASIS(®) is the first prescription eye drop to target the underlying cause of chronic Dry Eye.

Abstract: Azasite for posterior blepharitis

Efficacy of azithromycin 1% ophthalmic solution for treatment of ocular surface disease from posterior blepharitis.
Clin Exp Optom. 2010 Nov 17. doi: 10.1111/j.1444-0938.2010.00540.x. [Epub ahead of print]
Opitz DL, Tyler KF.
Illinois College of Optometry, Chicago, Illinois, USA Midwest Eye Professionals, Palos Heights, Illinois, USA

Posterior blepharitis is an eyelid disease primarily of the meibomian glands. Bacteria and chronic inflammation are contributing factors for meibomian gland disease, which leads to ocular surface and tear film alterations and chronic patient symptoms. Azithromycin 1.0% ophthalmic solution is a broad spectrum topical antibiotic with anti-inflammatory properties. The present study evaluates the efficacy of azithromycin 1.0% ophthalmic solution in the treatment of the clinical signs and symptoms, including vision-related function, associated with meibomian gland dysfunction.

In an open label study, 33 patients with meibomian gland dysfunction were treated with azithromycin 1.0% ophthalmic solution twice a day for two days, then every evening for a total of 30 days. Tear break-up time, corneal staining, conjunctival staining, Schirmer scores with anaesthetic, meibomian gland score and patient's symptom scores were evaluated at baseline and after 30 days of treatment. The Ocular Surface Disease Index (OSDI) was administered at baseline, after two weeks of treatment and after 30 days of treatment.

Twenty-six of 33 patients completed the study. Tear break-up time and Schirmer score increased by 52.7 per cent (p < 0.0001) and 24 per cent (p < 0.05), respectively. There was a reduction in corneal and conjunctival staining by 83.2 and 67.9 per cent, respectively (p < 0.0001). Lid margin scores were reduced by 33.9 per cent (p < 0.0001). The patient's symptom score improved from 2.73 at baseline to 2.21 after 30 days of treatment (p < 0.01). The mean OSDI at baseline was 34.44. After two weeks and 30 days of treatment, the ODSI was 14.51 and 13.15 respectively (p < 0.0001).

These results demonstrate clinically and statistically significant improvement in the signs and symptoms associated with posterior blepharitis. Based on these results, azithromycin 1% ophthalmic solution offers a viable option for the treatment of posterior blepharitis.

Abstract: Avoiding problems in cosmetic eyelid surgery

Eyelid surgeries are a significant cause of dry eye. If you ever consider it, you should have a good corneal specialist involved and make sure the oculaplast really "gets" the issues that can affect the ocular surface.

I really appreciate that in this abstract the author specifically refers to previous LASIK as well as other dry eye risk factors. For too many, eyelid surgery was the the last straw.

Complications in periocular rejuvenation.
Facial Plast Surg Clin North Am. 2010 Aug;18(3):435-56.
Mack WP.
Division of Oculoplastics Surgery, University of South Florida, Tampa, FL, USA.

Thorough preoperative evaluation with meticulous surgical planning to achieve facial aesthetic balance between the forehead, eyelids, and midface is imperative to avoid or decrease potential functional and/or cosmetic complications in cosmetic periocular surgery. Before performing surgery, the physician should be aware of the patient's history of dry eyes, previous facial trauma, previous injection of Botox Cosmetic, history of previous laser-assisted in situ keratomileusis, and past facial surgery. A full evaluation should be performed on the upper eyelid/brow region to assess for the presence of brow ptosis, brow/eyelid asymmetry, dermatochalasis/pseudodermatochalasis, eyelid ptosis, and deep superior sulcus. On the lower eyelid/cheek examination, special attention should be directed to the diagnosis of underlying negative vector, dry eyes, prominent eyes, lower lid retraction, ectropion, lateral canthal dystopia, lower eyelid laxity, scleral show, and lagophthalmos, with a rejuvenation goal that focuses on obtaining a youthful fullness through repositioning and reinforcing efforts to avoid the negative effects of hollowness. Intraoperative and postoperative medical and surgical management of cosmetic periocular surgery complications focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hemorrhage.

Abstract: Recalling dry eye symptoms

This is quite an interesting study, all about how well we recall our symptoms. And we remembered pretty darned well, especially if it hurt a lot.

I'd be much more interested to see something tracking this over a longer period. I think most dry eye patients have a pretty good handle on their short term ups and downs - however, longer term it's much harder, which is one of the reasons why I think it's quite useful to complete an OSDI at regular intervals (as well as have objective tests done at the doctor's) to be able to more objectively track our progress and our response to treatments we're on.

Temporal stability in the perception of dry eye ocular discomfort symptoms.
Optom Vis Sci. 2010 Dec;87(12):1023-9.
Cardona G, Marcellán C, Fornieles A, Vilaseca M, Quevedo L.
*PhD †MSc Department of Optometry, University Vision Centre, Universitat Politècnica de Catalunya, Terrassa, Catalonia, Spain (GC, CM, LQ), Centre for Sensors, Instruments and Systems Development (CD6), Universitat Politècnica de Catalunya, Terrassa, Catalonia, Spain (MV), and Psychobiology and Health Sciences Methodology Department, Universitat Autònoma de Barcelona, Bellaterra, Spain (AF).

A prospective longitudinal study was designed to investigate the ability of patients with tear deficiency to correctly recall their past symptoms. The ultimate goal of the study was to contribute to the ongoing research concerning the lack of association between dry eye symptomatology and clinical tests of tear film evaluation.

A total of 26 subjects with ages ranging from 29 to 61 years participated in the study. All subjects reported symptoms associated with tear deficiency, although none had been diagnosed with dry eye disease. Subjects were instructed to grade their symptoms on two different occasions, at the precise moment they were experiencing them, by means of a home questionnaire, and through a recall questionnaire, which was administered within a maximum interval of 10 days from the first questionnaire. Tear evaluation tests were performed at this second time. Non-parametric statistical analyses were used to investigate the relationship between present and recalled symptoms and between symptoms and signs, as well as between the different dry eye tests. The contributions of age, gender, and recall period were also evaluated.

With the exception of irritation (p = 0.029) and scratchiness (p = 0.025), no statistically significant difference was encountered between home and recall questionnaires, although females were found to recall their symptoms slightly better than males (p = 0.048). An increase in the severity of the symptoms was associated with a better recollection (p = 0.007). Symptoms (home or recalled) and clinical signs were not correlated, although the recalled symptom of scratchiness presented moderately strong correlations with several dry eye tests.

Although the lack of correlation between dry eye tests and symptoms mirrored previous research, symptoms recall was found to follow certain interesting patterns, similar to those published in pain research literature.

Abstract: Punctal plugs as a tool for Restasis drug delivery

Ophthalmic delivery of cyclosporine a by punctal plugs.
J Control Release. 2010 Nov 11. [Epub ahead of print]
Gupta C, Chauhan A.

Dry eyes are treated by instillation of eye drops of cyclosporine A emulsion or by punctal plug insertion in canaliculus to block tear drainage. This paper focuses on a novel approach of developing a punctal plug that can also release cyclosporine A to provide a dual mechanism for treating dry eyes. The punctal plug consists of a cylindrical hydroxy ethyl methacrylate core containing drug microparticles surrounded by an impermeable silicone shell that covers about 50% of the core, with the uncovered part directed towards the eyes. The geometry of this design is significantly different from those in patent literature, which are mostly designed to be rods. Plugs release cyclosporine A for a period of about 3months at zero-order at a rate of about 3μg/day. The in vivo release rates are expected to be about half of this value. A mathematical model is presented that provides an accurate estimate of the release without any fitting parameter. Pharmacokinetic models are also developed for drug delivered through Restasis® and punctal plugs, and based on these models the release rate of about 1.5μg/day may be therapeutically effective. The predictions of the ocular pharmacokinetic model are in reasonable agreement with reported measurements in humans.

Abstract: Discoid lupus erythematosus as rare cause of blepharitis

Palpebral involvement as a presenting and sole manifestation of discoid lupus erythematosus.
ScientificWorldJournal. 2010 Nov 4;10:2130-1.
Yaghoobi R, Feily A, Behrooz B, Yaghoobi E, Mokhtarzadeh S.
Department of Dermatology, Jundishapur University of Medical Sciences, Ahvaz, Iran.

A 28-year-old woman presented with a 2-year history of idiopathic, chronic blepharitis unresponsive to several courses treatment of corticosteroid eye drops. Physical examination was notable for edematous, erythematous plaques of the lower eyelids with madarosis in the absence of preceding skin scarring. Biopsy specimen was obtained and diagnosis of discoid lupus erythematosus (DLE) was made. DLE is a chronic, cutaneous disease that is clinically characterized by a malar rash, acute erythema, and discoid lesions. Localized DLE occurs when the head and neck only are affected, while widespread DLE occurs when other areas are affected, regardless of whether disease of the head and neck is seen. Patients with widespread involvement often have hematologic and serologic abnormalities, are more likely to develop systemic lupus erythematosus, and are more difficult to treat. A number of skin diseases may be confused with DLE, such as psoriasis, seborrheic dermatitis, acne, rosacea, lupus vulgaris, sarcoidosis, Bowen's disease, polymorphous light eruption, lichen planopilaris, dermatomyositis, granuloma annulare, and granuloma faciale. Palpebral lesions may rarely be the presenting or sole manifestation of the disease and lower eyelid involvement is seen in 6% of patients with chronic, cutaneous lupus erythematosus. DLE should therefore be considered as a differential diagnosis in chronic blepharitis or madarosis that persists despite usual medical management and eyelid hygiene. The patient was treated successfully with hydroxychloroquine. The skin lesions resolved with minimal scarring.

Abstract: Acupuncture for dry eye

Acupuncture for treating dry eye: a randomized placebo-controlled trial.
Acta Ophthalmol. 2010 Dec;88(8):e328-33. doi: 10.1111/j.1755-3768.2010.02027.x. Epub 2010 Nov 10.
Shin MS, Kim JI, Lee MS, Kim KH, Choi JY, Kang KW, Jung SY, Kim AR, Kim TH.
Korea Institute of Oriental Medicine, Daejeon, Korea.

PURPOSE: To evaluate the efficacy and safety of acupuncture for ocular symptoms, tear film stability and tear secretion in dry eye patients.

METHODS: This is a randomized, patient-assessor blinded, sham acupuncture controlled trial. Forty-two participants with defined moderate to severe dry eye underwent acupuncture treatment three times a week for 3 weeks. Seventeen standard points (GV23; bilateral BL2, GB14, TE23, Ex1, ST1 and GB20; and unilateral SP3, LU9, LU10 and HT8 on the left for men and right for women) with 'de qi' manipulation for the verum acupuncture group and seventeen sham points of shallow penetration without other manipulation for the sham group were applied during the acupuncture treatment. Differences were measured using the ocular surface disease index (OSDI), the visual analogue scale (VAS) of ocular discomfort, the tear film break-up time (BUT) and the Schimer I test with anaesthesia. In addition, adverse events were recorded.

RESULTS: There were no statistically significant differences between results on the OSDI, VAS, BUT or Schimer I tests from baseline between the verum and sham acupuncture groups. However, results from the within-group analysis showed that the OSDI and VAS in both groups and the BUT in the verum acupuncture group were significantly improved after 3 weeks of treatment. No adverse events were reported during this trial.

CONCLUSION: Both types of acupuncture improved signs and symptoms in dry-eye patients after a 4-week treatment. However, verum acupuncture did not result in better outcomes than sham acupuncture.

Drug news: Otsuka seeking approval for Rebamipide in Japan

Otsuka Pharmaceutical Files For Regulatory Approval In Japan For Mucosta® Ophthalmic Suspension For Dry Eye
Medical News Today - November 12, 2010

Otsuka Pharmaceutical Co., Ltd. announced it has applied for regulatory approval in Japan to manufacture and market Mucosta® (rebamipide) ophthalmic suspension for treatment of dry eye. Dry eye is a chronic condition of the corneal and conjunctival epithelia resulting from a range of factors, and involves subjective symptoms including ocular discomfort and visual disturbance.

By its novel mechanism of action to promote the production of mucin in the ocular surface (both the cornea and the conjunctiva), Mucosta ophthalmic suspension stabilizes the tear film and has demonstrated effectiveness in dry eye treatment. In a clinical trial conducted in Japan, it was confirmed that in addition to the improvement in corneal-conjunctival damage in patients with dry eye, Mucosta ophthalmic suspension also showed improvements in subjective symptoms.

Abstract: Herpes zoster ophthalmicus

I have just one word for herpes zoster in the eye... OUCH!!!!!!!!!!

I wish they had mentioned PROSE (Boston scleral) among treatments here as it can be helpful for the pain.

Herpes Zoster Ophthalmicus.
Curr Treat Options Neurol. 2010 Oct 12. [Epub ahead of print]
Sanjay S, Huang P, Lavanya R.
Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Alexandra Health, 90 Yishun Central, Singapore, 768828, Singapore,

OPINION STATEMENT: The management of herpes zoster (HZ) usually involves a multidisciplinary approach aiming to reduce complications and morbidity. Patients with herpes zoster ophthalmicus (HZO) are referred to ophthalmologists for prevention or treatment of its potential complications. Without prompt detection and treatment, HZO can lead to substantial visual disability. In our practice, we usually evaluate patients with HZO for corneal complications such as epithelial, stromal, and disciform keratitis; anterior uveitis; necrotizing retinitis; and cranial nerve palsies in relation to the eye. These are acute and usually sight-threatening. We recommend oral acyclovir in conjunction with topical 3% acyclovir ointment, lubricants, and steroids for conjunctival, corneal, and uveal inflammation associated with HZO. Persistent vasculitis and neuritis may result in chronic ocular complications, the most important of which are neurotrophic keratitis, mucus plaque keratitis, and lipid degeneration of corneal scars. Postherpetic complications, especially postherpetic neuralgia (PHN), are observed in well over half of patients with HZO. The severe, debilitating, chronic pain of PHN is treated locally with cold compresses and lidocaine cream (5%). These patients also receive systemic treatment with NSAIDs, and our medical colleagues cooperate in managing their depression and excruciating pain. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. Ocular surgery for HZO-related complications is performed only after adequately stabilizing pre-existing ocular inflammation, raised intraocular pressure, dry eye, neurotrophic keratitis, and lagophthalmos. Cranial nerve palsies are common and most often involve the facial nerve, although palsy of the oculomotor, trochlear, and abducens nerves may occur in isolation or (rarely) simultaneously. In our setting, complete ophthalmoplegia is seen more often than isolated palsies, but recovery is usually complete. Vasculitis within the orbital apex (orbital apex syndrome) or brainstem dysfunction is postulated to be the cause of cranial nerve palsies. A vaccine of a lyophilized preparation of the oka strain of live, attenuated varicella-zoster virus is suggested for patients who are at risk of developing HZ and has been shown to boost immunity against HZ virus in older patients.

Abstract: Curcumin

Interesting. Curcumin has been used in dry eye nutritional supplements for quite some time.

Management of chronic anterior uveitis relapses: efficacy of oral phospholipidic curcumin treatment. Long-term follow-up.
Clin Ophthalmol. 2010 Oct 21;4:1201-6.
Allegri P, Mastromarino A, Neri P.
Uveitis Center, Ophthalmological Department of Lavagna Hospital, Genova, Italy.

Curcumin has been successfully applied to treat inflammatory conditions in experimental research and in clinical trials. The purpose of our study is to evaluate the efficacy of an adjunctive-to-traditional treatment with Norflo tablets (curcumin-phosphatidylcholine complex; Meriva) administered twice a day in recurrent anterior uveitis of different etiologies. The study group consisted of 106 patients who completed a 12-month follow-up therapeutic period. We divided the patients into three main groups of different uveitis origin: group 1 (autoimmune uveitis), group 2 (herpetic uveitis), and group 3 (different etiologies of uveitis). The primary end point of our work was the evaluation of relapse frequency in all treated patients, before and after Norflo treatment, followed by the number of relapses in the three etiological groups. Wilcoxon signed-rank test showed a P < 0.001 in all groups. The secondary end points were the evaluation of relapse severity and of the overall quality of life. The results showed that Norflo was well tolerated and could reduce eye discomfort symptoms and signs after a few weeks of treatment in more than 80% of patients. In conclusion, our study is the first to report the potential therapeutic role of curcumin and its efficacy in eye relapsing diseases, such as anterior uveitis, and points out other promising curcumin-related benefits in eye inflammatory and degenerative conditions, such as dry eye, maculopathy, glaucoma, and diabetic retinopathy.

Abstract: Systane vs. Optive

Nobody wins....

Effect of systane and optive on aqueous tear evaporation in patients with dry eye disease.
Eye Contact Lens. 2010 Nov;36(6):358-60.
Wojtowicz JC, Arciniega JC, McCulley JP, Mootha VV.
Department of Ophthalmology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-9057, USA.

OBJECTIVE: To compare the effect on aqueous tear (AT) evaporation rate of Systane and Optive at 30 min postinstillation in patients with dry eye.

METHODS: In a crossover study of 20 patients with keratoconjunctivitis sicca, the evaporation rate of AT was measured. Evaporometry was used at two relative humidity (RH) ranges of 25% to 35% and 35% to 45%. The measurements were made at baseline (before the instillation of the study agent) and at 30 min after the instillation of 40 μL of either Systane or Optive per randomization assignment per visit with a 1-week interval between visits.

RESULTS: No significant effects on AT evaporation rates at both RHs were found between study agents.

CONCLUSIONS: In our study, neither Systane nor Optive has a significant impact on AT evaporation at 30 min postinstillation in patients with dry eye.

Abstract: Kids, contacts and dry eye

You know, I find the trend to fit younger and younger children with contacts very disturbing. We know from the literature that tear film degrades with age and is at its very best in childhood. Since their tear film is best able to support a lens... this means it's OK to give them lenses and thus extend the years they're going to expose their eyes to this risk?

I myself started wearing contacts in 6th grade, which was unusual back in those days. There was a reason, though, and I certainly didn't seek contacts on my own. I was a very high myope and always had some trouble seeing well with glasses. They tried to put hard lenses on me and it didn't work out. A year or so later I started wearing soft lenses. Over time more and more peers joined me. I kind of think that the younger you start wearing contacts, the more potential for getting really well established in poor eyecare habits. To this day I shudder to think of how I cared for (or didn't) those contacts. During my mid teens I think I did alright, but during late teens and early twenties, I suppose I succumbed to the invincible attitude typical of those ages, not to mention the starving student's attitude to paying for eyecare.

If I could do it all over again, I really think I would have stuck with glasses. But it would have been much easier if small frames had been fashionable when I was young. They weren't, and large frames looked ridiculous in my prescription.

Dry eye in pediatric contact lens wearers.
Eye Contact Lens. 2010 Nov;36(6):352-5.
Greiner KL, Walline JJ.
Davis Duehr Dean Eye Care, Madison, WI, USA.

OBJECTIVE: To determine whether children who wear contact lenses truly have fewer dry eye complaints than adults do.

METHODS: Ninety-four pediatric contact lens wearers, aged 8 to 14 years, were recruited and given the Contact Lens Dry Eye Questionnaire (CLDEQ) short form. The survey is designed to diagnose dry eye syndrome by obtaining information on the frequency of dryness and light sensitivity and their corresponding intensity levels within the first 2 hr of putting in the lenses, in the middle of the day, and at the end of the day. The responses were scored by multiplying the frequency by the average intensity and a constant. A composite score was calculated by subtracting the photophobia score from the dryness score, and the results were compared with those of adult samples from the literature. The questionnaire also asked whether the subject believed he or she had dry eyes while wearing contact lenses. Subjects who believed that they had dry eyes and exhibited a CLDEQ composite score >0.03 were diagnosed with dry eye. Subjects who were unsure if they had dry eyes or said they did not have dry eyes but scored >1.29 were also diagnosed with dry eye.

RESULTS: The average (±SD) age of the sample was 11.7 ± 1.5 years, 56.4% were female, 59.6% were white, and 19.1% were black. The mean (±SD) CLDEQ composite score was 0.25 ± 0.50 (range = -1.20 to 1.45). In the literature, the adult mean (±SD) CLDEQ composite score was 1.02 ± 0.80 (range = -0.74 to 4.50). Of the 94 surveys collected, 4.3% of children were categorized as having dry eye compared with 56.2% of the adults who completed the CLDEQ survey in the adult study.

CONCLUSIONS: Pediatric contact lens wearers have fewer complaints about dry eyes than do adult contact lens wearers, which may be because of improved tear film, differences in reporting of symptoms, or modality of contact lens wear.

Abstract: Causes of inflammation in Demodex-induced bleph

Tear cytokines and chemokines in patients with Demodex blepharitis.
Cytokine. 2011 Jan;53(1):94-9. Epub 2010 Nov 2.
Kim JT, Lee SH, Chun YS, Kim JC.
Department of Ophthalmology, College of Medicine, Chung-Ang University, Yongsan Hospital, 65-207, Hangangro-3Ga, Yongsan-Gu, Seoul 140-757, Republic of Korea.

PURPOSE: The purpose of the study is to evaluate the causes of inflammation in Demodex-induced blepharitis by analyzing cytokine levels in lacrimal fluid.

METHODS: Fifteen Demodex blepharitis patients were selected for assessment of tear cytokine concentrations. Fifteen Demodex-free blepharitis patients and 15 subjects with no ocular symptoms were selected as control groups. Minimally stimulated tear samples (20μl) were collected from each eye and analyzed using a Luminex® 200™ Total System for detection of IL-1β, IL-5, IL-7, IL-12, IL-13, IL-17, granulocyte colony-stimulating factor (G-CSF), and macrophage inflammatory protein-1 beta (MIP-1β).

RESULTS: The concentration of IL-17 in tears was significantly higher in the Demodex blepharitis group than in the Demodex-free blepharitis group. Tear IL-7 and IL-12 levels show serial increases for these three groups (p<0.05). There were no significant differences in the other cytokines levels between both blepharitis groups. We confirmed that elevated cytokines normalized after treatments.

CONCLUSIONS: Infestation of Demodex mites induces change of tear cytokine levels, IL-17 especially, which cause inflammation of the lid margin and ocular surface. These findings might increase our understanding of the mechanism of ocular discomfort and telangiectasias frequently found in Demodex blepharitis patients.

Recruiting for study: Omega 3 study in Houston (post-menopausal women)

Post-menopausal women over 40 needed for dry eye study

Women over the age of 40 who are past menopause can take part in a research study evaluating omega-3 fatty acids or fish oil as a treatment for dry eye.

Recruiting for study: Omega 3 study in Houston

Post-menopausal women over 40 needed for dry eye study

Women over the age of 40 who are past menopause can take part in a research study evaluating omega-3 fatty acids or fish oil as a treatment for dry eye.

Abstract: Surfactant properties of human meibomian lipids

Surfactant properties of human meibomian lipids.
Invest Ophthalmol Vis Sci. 2010 Nov 4. [Epub ahead of print]
Mudgil P, Millar TJ.
School of Natural Sciences, University of Western Sydney, Penrith South DC, Australia.

Human meibomian lipids are the major part of the lipid layer of the tear film. Their surfactant properties enable their spread across the aqueous layer and help maintain a stable tear film. The purpose of this study was to investigate surfactant properties of human meibomian lipids in vitro and to determine effects of different physical conditions such as temperature and increased osmolarity, such as occurs in dry eye, on these properties.

Methods: Human meibomian lipids were spread on an artificial tear solution in a Langmuir trough. The lipid films were compressed and expanded to record the surface pressure-area (Π-A) isocycles. The isocycles were recorded under different physical conditions such as high pressure, increasing concentration and size of divalent cations, increasing osmolarity, and varying temperature.

Results: Π-A isocycles of meibomian lipids showed that they form liquid films which are compressible and multilayered. The isocycles were unaffected by increasing concentrations or size of divalent cations and increasing osmolarity in the subphase. Temperature had a marked effect on the lipids. Increase in temperature caused lipid films to become fluid, an expected feature, but decrease in temperature unexpectedly caused expansion of lipids and an increase in pressure suggesting enhanced surfactant properties.

Conclusions: Human meibomian lipids form highly compressible, non-collapsible, multilayered liquid films. These lipids have surfactants that allow them to spread across an aqueous subphase. Their surfactant properties are unaffected by increasing divalent cations or hyperosmolarity but are sensitive to temperature. Cooling of meibomian lipids enhances their surfactant properties.

Abstract: Diagnosing obstructive MGD vs. aqueous deficient dry eye

I highlighted just one sentence below which I thought was quite interesting. Between aqueous deficient dry eye (naughty lacrimal glands) and obstructive MGD (naughty meibomian glands) not just the symptoms were similar BUT also the lid margins looked the same and the TBUT was similar. Phew. For a moment there I almost felt a little more sympathy for doctors who chronically overlook MGD. But only for a moment. Docs, ya gotta educate yerselves about MGD. Really.

Efficacy of diagnostic criteria for the differential diagnosis between obstructive meibomian gland dysfunction and aqueous deficiency dry eye.
Jpn J Ophthalmol. 2010 Sep;54(5):387-91. Epub 2010 Nov 5.
Arita R, Itoh K, Maeda S, Maeda K, Tomidokoro A, Amano S.
Itoh Clinic, Saitama, Japan.

PURPOSE: To evaluate diagnostic criteria for obstructive meibomian gland dysfunction (MGD) using three parameters (symptom score, lid margin abnormality score, and meibomian gland morphologic change scores) for differentiating obstructive MGD from aqueous deficiency dry eye (ADDE).

METHODS: Twenty-five eyes of 25 patients (mean age, 66.6 years) diagnosed with obstructive MGD and 15 eyes of 15 patients (mean age, 61.3 years) diagnosed with ADDE were analyzed. Ocular symptoms were scored from 0 to 14 according to the number of symptoms. Lid margin abnormality was scored from 0 to 4 according to the number of abnormalities. Meibomian gland changes were scored from 0 to 6 using noncontact meibography (meibo-score). Superficial punctate keratopathy was scored from 0 to 3. Meibum was graded from 0 to 3 according to volume and quality. Tear film break-up time was measured consecutively three times after instillation of fluorescein, and the median value was adopted. Tear film production was evaluated using the Schirmer test.

RESULTS: Ocular symptom and lid margin abnormality scores and tear film break-up time did not differ significantly between the obstructive MGD and ADDE groups. The meibum score and meibo-score were significantly higher in the obstructive MGD group than in the ADDE group. The Schirmer value was significantly lower in the ADDE group than in the obstructive MGD group. When obstructive MGD was diagnosed on the basis of three scores (ocular symptom score, lid margin abnormality score, and meibo-score) all being abnormal, the sensitivity and specificity for differentiating between obstructive MGD and ADDE were 68.0% and 80%, respectively.

CONCLUSIONS: Although the criteria were moderately reliable for differentiating patients with obstructive MGD from those with ADDE when the diagnosis of obstructive MGD was made on the basis of three abnormal scores, they do not provide comprehensive diagnostic tools for differentiating MGD, ADDE, and healthy individuals. We need to add other parameters such as the Schirmer test value and the meibum score to the diagnostic criteria to enhance their reliability for differentiating MGD and ADDE.

Abstract: Sodium hyaluronate and carboxymethylcellulose

This kind of study drives me nuts, because irrespective of the validity of the data, it never tells the real story.

Sounds like a simple proposition: Compare a sodium hyaluronate drop to a carboxymethylcellulose drop. (They're all alike, a dime a dozen, right?) And conclude that they both made people's eyes wetter. Get out. Really? And we all nod and say, I told you so, all artificial tears are more or less the same. But are they?

Back in the days (wave of nostalgia coming...) when I had a little capital and I was able to be more involved with my beloved Dr. Holly's drops, I got a little much-needed education on what goes on in these drops that never shows up on the label... or the study abstract, and probably not even in the whole paper. Take Dwelle for instance. It's povidone and polyvinyl alcohol. Big deal. There's several drops with these ingredients on the market and I think I won't hurt anyone's feelings if I say none of them has ever been thought earth-shattering. Tried one PVA drop, tried 'em, all, right? No, actually, Dr. Holly's drops have a combination of grades of PVA not used in any other drop and this combination (along with the additional polymer) creates uniquely high oncotic pressure values which is what makes his drops effective especially for those with a compromised epithelium.

So circling back to sodium hyaluronate... My industry friends say it's all about the molecular weight. All SH drops are NOT equal, just as all PVA drops are NOT equal.

Bottom line: Do your homework on drops. Don't write them off (and likewise, don't embrace them) just because of a fancy name in the active or in some cases inactive ingredients. Sometimes what's NOT on the label is more telling than what is.

Efficacy of Sodium Hyaluronate and Carboxymethylcellulose in Treating Mild to Moderate Dry Eye Disease.
Cornea. 2010 Oct 28. [Epub ahead of print]
Lee JH, Ahn HS, Kim EK, Kim TI.
From the Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea.

PURPOSE: We compared the efficacy and safety of sodium hyaluronate (SH) and carboxymethylcellulose (CMC) in treating mild to moderate dry eye.

METHODS: Sixty-seven patients with mild to moderate dry eye were enrolled in this prospective, randomized, blinded study. They were treated 6 times a day with preservative-free unit dose formula eyedrops containing 0.1% SH or 0.5% CMC for 8 weeks. Corneal and conjunctival staining with fluorescein, tear film breakup time, subjective symptoms, and adverse reactions were assessed at baseline, 4 weeks, and 8 weeks after treatment initiation.

RESULTS: Thirty-two patients were randomly assigned to the SH group and 33 were randomly assigned to the CMC group. Both the SH and CMC groups showed statistically significant improvements in corneal and conjunctival staining sum scores, tear film breakup time, and dry eye symptom score at 4 and 8 weeks after treatment initiation. However, there were no statistically significant differences in any of the indices between the 2 treatment groups. There were no significant adverse reactions observed during follow-up.

CONCLUSIONS: The efficacies of SH and CMC were equivalent in treating mild to moderate dry eye. SH and CMC preservative-free artificial tear formulations appropriately manage dry eye sign and symptoms and show safety and efficacy when frequently administered in a unit dose formula.

Abstract: Theratears Nutrition

This is kind of, sort of a little bit interesting. Test everyone. Give everyone fish & flaxseed oil daily for three months. Then test 'em again. On the one hand, it sounds like very little changed for anybody in terms of clinical findings. On the other hand, 70% "became asymptomatic". WTH? I'd like to know what they were like to start with. The interesting part is, the authors' conclusions was that it may have helped tear production but didn't do a thing for the lipids or TBUT.

Pilot, Prospective, Randomized, Double-masked, Placebo-controlled Clinical Trial of an Omega-3 Supplement for Dry Eye.
Cornea. 2010 Oct 28. [Epub ahead of print]
Wojtowicz JC, Butovich I, Uchiyama E, Aronowicz J, Agee S, McCulley JP.
From the Department of Ophthalmology, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX.

PURPOSE: To investigate the potential effect of dietary supplementation with omega-3 fatty acid on lipid composition of meibum, aqueous tear evaporation, and tear volume in patients with dry eye.

METHODS: In a pilot, prospective, randomized, double-masked study, patients with dry eye received a daily dose of fish oil, containing 450 mg of eicosapentaenoic acid, 300 mg of docosahexaenoic acid, and 1000 mg of flaxseed oil (TheraTears Nutrition; Advanced Vision Research, Woburn, MA) for 90 days. There were 2 patient visits: baseline and final. At these visits, patients completed the ocular surface disease index to score subjective symptoms, and slit-lamp examinations, breakup time, corneal staining, Schirmer type I, fluorophotometry, evaporometry, and collection of meibomian gland secretion samples for lipid composition analysis were performed.

RESULTS: A total of 36 patients with dry eye completed the study. At the end of the study, 70% of the patients became asymptomatic, whereas for the placebo group, 7% of the symptomatic patients became asymptomatic. Schirmer testing and fluorophotometry suggested that the omega-3 supplement increased tear secretion. The lipid composition of the samples collected from the omega-3 group was found to be very similar to that from the placebo group. No trends between groups were seen for other objective parameters.

CONCLUSIONS: Dietary supplementation with omega-3 fatty acids in dry eye showed no significant effect in meibum lipid composition or aqueous tear evaporation rate. On the other hand, the average tear production and tear volume was increased in the omega-3 group as indicated by both Schirmer testing and fluorophotometry.

Abstract: The economic burden of dry eye disease in the US

This is an interesting summary of estimated costs of managing dry eye. I wonder where they got their recruits? I wish somebody would recruit some DryEyeTalk members.

I suspect this study is looking at people with considerably milder dry eye symptoms than your average DryEyeTalk member or DryEyeBulletin reader. The $783 estimated total annual cost per patient supposedly covers all direct (medical, OTC, etc) and indirect costs. Geez, most dry eye patients I know spend something in that neighborhood annually just in over-the-counter products and eyewear, let alone the cost of doctor visits and prescription drugs and indirect costs like lost workdays. In fact I know an awful lot of people who spend that much on artificial tears each year.

I suppose it is progress that they've included the cost of nutritional supplements, not just drugs, but someday I'd like to see a study that includes things like night goggles and moisture chambers, since protective eyewear is increasingly being recognized as a vital tool for severe dry eye and is usually the highest dollar item on the dry eye shopping list.

The Economic Burden of Dry Eye Disease in the United States: A Decision Tree Analysis.
Cornea. 2010 Oct 28. [Epub ahead of print]
Yu J, Asche CV, Fairchild CJ.
From the *University of Utah, College of Pharmacy, Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City, UT; and †Alcon Research, Ltd, Fort Worth, TX.

The aim of this study was to estimate both the direct and indirect annual cost of managing dry eye disease (DED) in the United States from a societal and a payer's perspective.

A decision analytic model was developed to estimate the annual cost for managing a cohort of patients with dry eye with differing severity of symptoms and treatment. The direct costs included ocular lubricants, cyclosporine, punctal plugs, physician visits, and nutritional supplements. The indirect costs were measured as the productivity loss because of absenteeism and presenteeism. The model was populated with data that were obtained from surveys that were completed by dry eye sufferers who were recruited from online databases. Sensitivity analyses were employed to evaluate the impact of changes in parameters on the estimation of costs. All costs were converted to 2008 US dollars.

Survey data were collected from 2171 respondents with DED. Our analysis indicated that the average annual cost of managing a patient with dry eye at $783 (variation, $757-$809) from the payers' perspective. When adjusted to the prevalence of DED nationwide, the overall burden of DED for the US healthcare system would be $3.84 billion. From a societal perspective, the average cost of managing DED was estimated to be $11,302 per patient and $55.4 billion to the US society overall.

CONCLUSIONS: DED poses a substantial economic burden on the payer and on the society. These findings may provide valuable information for health plans or employers regarding budget estimation.