Latest Dwelle update

Straight from the horse's proverbial mouth,

...the cartons will be in early next week. Dwelle should ship late this month. They are behind on packaging.

More of the same that is. Hopefully accurate THIS time.

Support groups: Stuart, FL

East Florida Eye Institute in Stuart, FL is resuming monthly dry eye support group meetings. They will have one in August and I will post again when they have fixed a date.

Abstract: Mice blah blah blah improvement blah blah decreased inflammation

Confession: I start flagging even at T cell talk these days. When we get to CCR2 antagonists, interleukins 1alpha and 1beta my attention's gone until the conclusions, which have some of the right words.

Arch Ophthalmol. 2009 Jul;127(7):882-7. Amelioration of murine dry eye disease by topical antagonist to chemokine receptor 2.

Goyal S, Chauhan SK, Zhang Q, Dana R.
Schepens Eye Research Institute, Boston, MA 02114, USA.

OBJECTIVE: To determine the effect of a topical antagonist to the chemokine receptor 2 (CCR2) in a murine model of dry eye disease.

METHODS: The effects of a topical CCR2 antagonist and a vehicle control treatment were studied in murine dry eyes. A controlled environment chamber induced dry eye by exposing mice to high-flow desiccated air. Corneal fluorescein staining and enumeration of corneal CD11b(+) and conjunctival CD3(+) T cells were performed in the different groups. Real-time polymerase chain reaction was performed to quantify expression of different inflammatory cytokine transcripts in the cornea and conjunctiva.

RESULTS: Eyes receiving the formulation containing CCR2 antagonist showed a significant decrease in corneal fluorescein staining and decreased infiltration of corneal CD11b(+) cells and conjunctival T cells compared with the vehicle-treated and untreated dry eye groups. The CCR2 antagonist also significantly decreased messenger RNA expression levels of interleukins 1alpha and 1beta in the cornea, and tumor necrosis factor alpha and interleukin 1beta in the conjunctiva.

CONCLUSION: Topical application of CCR2 antagonist is associated with significant improvement in dry eye disease and is reflected by a decrease in inflammation at the clinical, molecular, and cellular levels. Clinical Relevance Topical application of CCR2 antagonist may hold promise as a therapeutic modality in dry eye disease.

Abstract: Dry eye in Canada

Hmmmm. I am sure some of my Canadian readers are hoping their doctor was privy to this 'consensus'!

If not, and your doctor is still offering you a generic "dry eye" diagnosis, tears and plugs and goodbye, my suggestion is to print out this statement below and fax it to your doctor the day before your next appointment, along with a brief bullet point synopsis of your goals for the appointment.

Management of dysfunctional tear syndrome: a Canadian consensus.
Can J Ophthalmol. 2009 Aug;44(4):385-94.
Jackson WB.
University of Ottawa Eye Institute, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, Canada. bjackson@ohri.ca

Dry eye complaints are common, have a diverse etiology, and result from disruption of the normal tear film; hence, the term "dysfunctional tear syndrome." Recent research has shown that ocular surface disorders have an inflammatory origin, that inflammation of the ocular surface does not always manifest as "red eye," and that a patient does not have to have a systemic autoimmune disease to experience a local, ocular autoimmune event. A panel of Canadian cornea and external disease subspecialists met and developed a questionnaire and treatment algorithm to aid the comprehensive ophthalmologist. Management of ocular surface disorders begins with a review of the patient's medical history, with particular attention to medication use, and a thorough ophthalmological examination. Use of a simple questionnaire can aid in the diagnosis. A variety of treatment modalities are available, the most effective of which are those that target the underlying inflammatory process with the goal of restoring the normal tear film. A treatment algorithm is presented that matches the severity of symptoms with the intensity of treatment. Lifestyle modifications, regular hygiene, and tear supplements may be sufficient in patients with mild symptoms. Anti-inflammatory medications (topical cyclosporin A, short courses of topical steroids, and [or] oral tetracyclines) and physical measures (punctal plugs, moisture-retaining eye wear) are implemented for those with moderate-to-severe symptoms. Autologous serum tears, scleral contact lenses, and surgery are reserved for patients with severe symptoms who have an unsatisfactory response to anti-inflammatory medications. Patients with lid disease or rosacea and those with allergic conditions should be identified during the initial encounter and should receive specific therapy to relieve their symptoms.

Abstract: OMGD treatments & evaluation with confocal

This is kind of an interesting one, studying obstructive meibomian gland disease via confocal microscopy in patients treated with an antiinflammatory or just with unpreserved tears and sodium hyaluronate. Unsurprisingly, the artificial tears really didn't improve anything clinically. Wish there had been some comparison with other treatments.

Graefes Arch Clin Exp Ophthalmol. 2009 Jun;247(6):821-9. Epub 2008 Dec 20.
The evaluation of the treatment response in obstructive meibomian gland disease by in vivo laser confocal microscopy.

Matsumoto Y, Shigeno Y, Sato EA, Ibrahim OM, Saiki M, Negishi K, Ogawa Y, Dogru M, Tsubota K.
Johnson & Johnson Department of Ocular Surface and Visual Optics, Keio University School of Medicine, Tokyo, Japan.

PURPOSE: To evaluate the status of periglandular inflammation, ocular surface and tear function alterations in patients with obstructive meibomian gland disease (OMGD) by in vivo confocal microscopy before and after anti-inflammatory treatment, and to compare the results with patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops without anti-inflammatory agents.

METHODS: Thirty-two eyes of 16 OMGD patients receiving anti-inflammatory treatment (treatment group) and 22 eyes of 11 OMGD patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops (control group) were recruited in this prospective study. All subjects underwent slit-lamp examinations, tear film break-up time (BUT) measurements, fluorescein and Rose-Bengal stainings, Schirmer test capital I, Ukrainian without anesthesia, transillumination of the lids (meibography), and in vivo laser confocal microscopy of the lids (HRTII-RCM).

RESULTS: The mean BUT, fluorescein staining scores, and inflammatory cell densities observed by in vivo confocal microscopy improved significantly in the group receiving anti-inflammatory treatment (p < 0.05), whereas no significant alterations of these parameters were observed in the group not receiving anti-inflammatory agents (p > 0.05).

CONCLUSIONS: In vivo confocal microscopy was able to effectively demonstrate the treatment responses in patients with OMGD. Inflammatory cell density calculation seems to be a promising new parameter of in vivo confocal microscopy in the evaluation of treatment responses.

Abstract: MMP9 as a dry eye marker

Production and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome.
Invest Ophthalmol Vis Sci. 2009 Jul;50(7):3203-9. Epub 2009 Feb 28.
Chotikavanich S, de Paiva CS, Li de Q, Chen JJ, Bian F, Farley WJ, Pflugfelder SC.
Department of Ophthalmology, Ocular Surface Center, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas 77030, USA.

PURPOSE: To evaluate production and activity of metalloproteinase (MMP)-9 on the ocular surface of patients with dysfunctional tear syndrome (DTS) and determine any correlation between MMP-9 activity and clinical parameters.

METHODS: Forty-six patients with newly diagnosed DTS and 18 control subjects were recruited. Complete ocular surface examinations were performed. Tear MMP-9 activity was assessed with an MMP-9 activity assay in 1 microL of unstimulated tear fluid. Using conjunctival epithelial cells from 19 patients with DTS and 16 controls, levels of MMP-9 and its regulating cytokine mRNA transcripts were evaluated by semiquantitative real-time PCR.

RESULTS: Each of four DTS severity-based groups had significantly higher mean MMP-9 activities than did the control group, which was 8.39 +/- 4.70 ng/mL. The DTS4 group had the highest MMP-9 activity (381.24 +/- 142.83 ng/mL), for which the mean was significantly higher than that of other DTS groups. In addition, patients with DTS had significantly higher levels of IL-1beta, IL-6, TNF-alpha, and TGF-beta1 mRNA transcripts in their conjunctival epithelia than did the control subjects. Tear MMP-9 activities showed significant correlation with symptom severity scores, decreased low-contrast visual acuity, fluorescein tear break-up time, corneal and conjunctival fluorescein staining, topographic surface regularity index (SRI), and percentage area of abnormal superficial corneal epithelia by confocal microscopy.

CONCLUSIONS: Tear MMP-9 activity was significantly higher in patients with DTS. This activity was associated with increased mRNA expression of MMP-9 and its regulating genes and correlated strongly with clinical parameters. MMP-9 appears to be a potentially useful biomarker for diagnosing, classifying, and monitoring DTS.

Abstract: Staining... what color, or does it matter?

OK so rose bengal and lissamine green basically performed the same except rose bengal was a little harder on the patients. But the really intriguing, if not new, finding here is that neither of them had any correlation to disease severity. And yes, thank you authors for using OSDI to rank disease severity. Maybe someday we really can end this silly business of telling patients they're fine because their corneal surface looks OK with little or no staining.

Staining Patterns in Dry Eye Syndrome: Rose Bengal Versus Lissamine Green.
Cornea. 2009 Jul 1. [Epub ahead of print]
Machado LM, Castro RS, Fontes BM.
From the *Department of Ophthalmology, State University of Campinas (UNICAMP), Campinas, Brazil; and daggerDepartment of Ophthalmology, Federal University of São Paulo (UNIFESP-EPM), São Paulo, Brazil.

PURPOSE:: To evaluate and compare corneal staining patterns of lissamine green (LG) versus rose bengal (RB) in patients with dry eye syndrome. Secondary objectives included addressing patient's comfort after instillation and to correlate disease severity with staining patterns.

METHODS:: Randomized, comparative, crossover series. Patients with previous diagnosis of mild to moderate dry eye syndrome were divided in 2 groups regarding dye instillation order (group A: RB first; group B: LG first). Both dyes were applied in regular intervals, and a staining score (van Bijsterveld scale) was used to correlate and compare the results. Disease severity was determined by the Ocular Surface Disease Index. Comfort was evaluated by patient's answer in an objective questionnaire.

RESULTS:: Sixty eyes of 30 consecutive patients (24 females and 6 males) were included. There was no statistical difference between groups regarding disease severity, sex, or age. LG and RB showed good clinical correlation in both groups (group A: r = 0.939, P < 0.001; group B: r = 0.915, P < 0.001). LG was better tolerated than RB (P = 0.003 in both groups). Overall, we found a low statistical correlation between disease severity and staining scores.

CONCLUSIONS:: Both LG and RB showed similar staining patterns. RB was found to provide greater patient discomfort. There was no correlation between disease severity (addressed by the ocular surface disease index questionnaire) and staining patterns (measured by the van Bijsterveld scale).

Abstract: Lipid layer thickness & dry eye symptoms

The Relationship Between Dry Eye Symptoms and Lipid Layer Thickness.
Cornea. 2009 Jul 1. [Epub ahead of print]
Blackie CA, Solomon JD, Scaffidi RC, Greiner JV, Lemp MA, Korb DR.

PURPOSE:: (1) To investigate the relationship between dry eye symptoms and lipid layer thickness (LLT) in patients presenting for routine eye examination and (2) to consider the practicality of interferometry in a clinical practice.

METHODS:: Patients presenting consecutively for routine eye examinations were recruited (n = 137, age range = 18-60 years, mean = 41.7 +/- 15.5 years, 102 females and 35 males). Patients were required to complete the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire after which their LLT was evaluated using a new interferometer (Ocular Surface Interferometer). Patients were assigned to 1 of 3 symptom categories: no symptoms (SPEED = 0), mild to moderate symptoms (SPEED = 1-9), and severe symptoms (SPEED >/= 10). Categorical analysis (contingency table) and linear regression were performed on the data.

RESULTS:: For patients with severe dry eye symptoms, 74% had an LLT /=75 nm (contingency table, chi = 12.63, df = 2, p = 0.0018). Furthermore, a linear regression of LLT and SPEED score reveal a significant linear relationship (as LLT increases, SPEED score decreases; p = 0.0014).

CONCLUSIONS:: (1) The data indicate that approximately 3 of 4 patients reporting severe symptoms have relatively thin lipid layers of 60 nm or less, whereas approximately 3 of 4 patients without symptoms have relatively thick lipid layers of 75 nm or more. Thus, the presence of dry eye symptoms significantly increases the likelihood of a relatively thin lipid layer. LLT seems to correlate better to symptoms, especially severe symptoms, than other reported correlations with objective clinical tests for dry eye disease. (2) Interferometry has the potential to be a practical and useful addition to clinical practice.

Abstract: Dry eye & geriatrics

Nice to see something on dry eye published in a geriatric journal:

Dry eye and blepharitis: approaching the patient with chronic eye irritation.
Gilbard JP.
Geriatrics. 2009 Jun;64(6):22-6.
Harvard Medical School, Boston, MA, USA.

Dry eye is the most common cause for chronic eye irritation in the patient over age 50 years and is multifactorial in etiology. Whatever the etiology, the final common pathway is loss of water from the tear film, with an increase in tear film osmolarity. Patients with dry eye experience sandy-gritty irritation, dryness, burning, or increased awareness of their eyes that gets worse as the day goes on. These patients need to be distinguished from patients with posterior blepharitis, or meibomitis, in which similar symptoms are worse on eye opening. Dry eye treatment includes strategies to lower tear film osmolarity and treat associated eyelid disease. The effectiveness of available treatments often leaves something to be desired. This condition may be severely disabling in advanced cases.

Dr. Toyos' and IPL

Ran across this newsblurb on Memphis local TV...

Dry Eye

Research has shown that about 10 percent of the adult population suffer from dry eye. Up until this point patients could only find relief by using drops and other medications which only help with some of the symptoms. Most dry eye is due to poorly functioning tear glands. A Memphis ophthalmologist, Dr. Rolando Toyos, has discovered a new treatment for dry eye utilizing a breakthrough technology called Intense Pulse Light. Dr. Toyos received a research grant 6 years ago to study this procedure and now has successfully treated over 1000 dry eye sufferers here in Memphis and in Beverly Hills, California. Patients have come from all over the world to receive this treatment. And Dr. Toyos has lectured here and internationally on the procedure. Just last month he presented his research in Rome at the Italian Ophthalmology Society Meeting.

There have been several discussions about IPL (intense pulsed light treatment) on Dry Eye Talk lately... here's one such thread: IPL with Dr. Toyos

Attention Aussies!

Your country is hosting a big dry eye meeting in early August. If you don't already have a good expert on your side, a list of attendees for that meeting would probably be a good way to find a doc who takes dry eye seriously.

International exchange to help solve dry eye
5 July 2009

The Institute for Eye Research and University of Western Sydney will host an international exchange of leading researchers to progress the development of solutions to the condition 'dry eye', from 3–8 August. Dry eye, the most common reason we seek medical help for an eye-related condition, and a major reason why people discontinue contact lens wear, affects around 100 million people worldwide.

Professor Mark Willcox, Chief Scientific Officer at the Institute, said that the gathering of experts from as far afield as Harvard, Stanford and Berkeley Universities in the US, Japan and Scotland, as well as Australia, will be an exciting opportunity to advance the experimental process in research of therapeutic treatments for dry eye.

"This exchange is an important step in reaching agreement on current research priorities as well as coordinating international research efforts in a way that will best advance the development of effective dry eye treatments," Professor Willcox said.

"The multi-disciplinary nature of this exchange, which includes specialists in the area of clinical optometry and ophthalmology, physical chemistry, biochemistry and theoretical mathematics, is a wonderful opportunity to take a giant leap forward in the experimental process by using different resource bases with guidance and knowledge from these experts. Additionally, it will provide the opportunity to broaden possibilities for collaboration and to enhance opportunities to obtain industry linked research funding, particularly through the added funding potential created by this cross fertilisation of research areas", Professor Willcox added.

Talk about a provocative title...

... for an editorial:

Controlling the ocular surface: How It's Done.
(Gary Foulks, The Ocular Surface Apr 2009)

Phew. I hope it's as easy as that sounds. Teach everybody, then I can farm full-time.

Abstract: Dry eye after cataract surgery

Very interesting work - confirming relationship between dry eye and cataract surgery and pinning down some technique-related risk factors.

Dry eye after cataract surgery and associated intraoperative risk factors.
Cho YK, Kim MS.
Korean J Ophthalmol. 2009 Jun;23(2):65-73. Epub 2009 Jun 9.
The Catholic University of Korea, St. Vincent's hospital, Suwon, Korea.

PURPOSE: To investigate changes in dry eye symptoms and diagnostic test values after cataract surgery and to address factors that might influence those symptoms and test results.

METHODS: Twenty-eight eyes from 14 patients with preoperative dry eye (dry eye group) and 70 eyes from 35 patients without preoperative dry eye (non-dry eye group) were studied prospectively. In each group, we measured values such as tear break-up time (tBUT), Schirmer I test (ST-I), tear meniscus height (TMH), and subjective dry eye symptoms (Sx), and evaluated the postoperative changes in these values. We also evaluated the influence of corneal incision location and shape on these values. The correlations between these values and microscopic light exposure time and phacoemulsification energy were investigated.

RESULTS: In the dry eye group, there were significant aggravations in Sx at 2 months postoperatively and in TMH at 3 days, 10 days, 1 month, and 2 months postoperatively, compared with preoperative values. All dry eye test values were significantly worse after cataract surgery in the non-dry eye group. With regard to incision location, there was no difference in tBUT, Sx, ST-I, or TMH in either the dry eye group or the non-dry eye group at any postoperative time point. Regarding incision shape, there was no difference in tBUT, Sx, ST-I or TMH at any postoperative time point in the dry eye group. In the superior incision sub-group of the non-dry eye group, tBUT and Sx were worse in the grooved incision group at day 1. In the temporal incision sub-group of the non-dry eye group, Sx were worse in the grooved incision group at 1 day, 3 days, and 10 days postoperatively. In both groups, significant correlations were noted between microscopic light exposure time and dry eye test values, but no correlation was noted between phacoemulsification energy and dry eye test values.

CONCLUSIONS: Cataract surgery may lead to dry eye. A grooved incision can aggravate the symptoms during the early postoperative period in patients without dry eye preoperatively. Long microscopic light exposure times can have an adverse effect on dry eye test values.

When you think you've got it rough...

...try to remember that at least we have a modern medical system to help with dry eye.

Yemeni traditions in treating eye problems

According to eye doctors, dry eye and eye sensitivity are the most widely spread complaints from Yemenis all around the country....

There are a number of practices that ancient Yemenis used to cure some eye diseases. "When your eye hurts because there is something in it or the like, you can go to a women whose job is to use her tongue to clean your eye," said Om Abdulwase'e' Al-Qadi a local women from Sana’a. However, there is no specific place to find this woman who licks eyes.

Vegetables also are of great importance, especially among welders who frequently suffer from eye pains. There is a traditional remedy by cutting a potato into pieces after which a welder will open his eyes and put each piece on one eye. “The potato should not be hot. Cold potato pieces purify eyes. Tomatoes can do the same to eyes by cutting it into pieces too,” said Ibraheem Sanad, a welder.

Another tradition is that when any one feels an irritating sensation in his or her eye, he or she can go to a woman called Al-Monaqishah who checks his or her eye using a needle. "When you feel that your eye hurts, you can go to Al-Monaqishah, as we call her. She has a needle and cotton or other soft material handy, and she starts checking your eyes to purify them by using a needle," said Nabilah Al-Khaiat, a house wife. She added that this can be done by any mature member in the family.

Modern medicine is of course represented there as well...

"Al-Monaqishah can check your eye but can also increase your pain. Moreover, she can bring a new disease to your eyes such as cancer or any other disease because of using a needle which is mainly made to sew clothes, not to check people’s eyes,” said Mohammed Abdullah Ibrahhim, an ophthalmic surgeon.

Ibrahhim added that even the substances known as 'Kohl,' a black substance, and 'Ethmed,' a brown substance, are proved to include the amount of lead in the body which may cause eye cancer. Ethmed was mentioned in the hadiths, or the sayings of the Prophet Muhammad. “Old Ethmed was known to purify the eyes and strengthen the eyesight, but today’s Ethmed is different and includes dangerous substances,” stated Ibrahhim.

That reminds me, didn't we have a long thread about Kohl awhile back on DryEyeTalk?

Drug news: Thumbs down to Rejena

US panel rejects River Plate, Alcon dry eye drug

SILVER SPRING, Md., June 26 (Reuters) - River Plate Biotechnology did not provide adequate evidence of safety and effectiveness for a proposed drug to treat dry eye, a U.S. advisory panel ruled on Friday.
The committee voted 6-1 against the drug, called Rejena. Alcon Inc (ACL.N) holds U.S. marketing rights for the product.