CORNEA 24 EWAP DECEMBER 2022 ASIA-PACIFIC PERSPECTIVES Sharon D’Souza, MD Consultant, Dept. of Cornea, Ocular Surface, and Refractive Service Chief Coordinator, Ocular Surface Clinic Narayana Nethralaya, Bangalore, India drsharondsouza@gmail.com Dry eye disease (DED) has shown an exponential increase in numbers in the last few years. We now understand that this multifactorial disease is associated with underlying inflammation, hyperosmolarity, and a loss of tear homeostasis irrespective of the underlying etiology.1 DED has classically been divided into aqueous deficient and evaporative dry eye depending on the alterations to the tear film but in clinical practice we do see a large overlap between these two entities.1 Thus, when treating dry eye, it is important to not only supplement the tear film components but also treat the inflammation and associated eyelid or other abnormalities. As it is a very dynamic and complex condition, a multipronged approach to diagnosis and management is key to optimal outcomes. One important challenge in the diagnosis of DED is the variability in symptoms which the patient presents with. Additionally, there can also be disparity between symptoms and signs due to increase in nociception or a neuropathic component.2,3 A detailed history including systemic health, nutrition, hormonal changes, occupation, and medications goes a long way in helping the clinician reach an accurate and complete diagnosis. A patient with primary or secondary Sjogren’s syndrome would require a detailed evaluation and blood investigations to measure disease activity and require systemic medications in addition to topical therapy.4 We have found an important association of systemic vitamin D deficiency with dry eye and wound healing and supplementation of these nutrients are also important in improving patient symptomatology and reducing inflammation.5,6 For patients with meibomian gland dysfunction (MGD) and evaporative dry eye, a thorough evaluation of the eyelids, meibomian gland expressibility for quality and quantity of meibum, changes like telangiectasia and pitting give a clue to the severity and chronicity of disease. In addition to medical therapy like warm compresses, lid hygiene, etc, procedural therapies have shown promising results. The vectored thermal pulsation therapy (Lipiflow, Johnson & Johnson, Jacksonville, FL, USA) and the intense pulsed light (Eye- light device, Espansione Marketing SPA., Bologna, Italy, and E-Eye, E-Swin, Houdan, France) have been useful in treating recalcitrant and chronic MGD and dry eye.7,8 They have a dual role of improving quality and quantity of meibomian secretions and reducing inflammation on the ocular surface.9 Controlling the ocular surface inflammation is key to managing chronic dry eye and cyclosporine 0.05% eye drops have been shown to have sustained and good results in improving signs and symptoms of dry eye. Various inflammatory factors like MMP -9 and Interleukins IL-6, 1β, 2, 4, 17, TNFα have been shown to be altered in patients with dry eye.10 An easy to use, tear-based, point-of-care biomarker analysis in the clinic which can measure multiple molecular factors at a go with immediate results is the next frontier in providing tailored personalized management of dry eye disease. (Bio- M Pathfinder, NovoMol -Dx, India, a customized version of the Ella™Automated ELISA system, Bio- Techne ® Corporation, Minnesota, USA). References 1. Craig JP, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017 Jul;15(3):276-283. 2. D’Souza S, et al. Corneal Confocal Microscopy Features and Tear Molecular Profile in Study Participants with Discordance between Ocular Surface Disease Clinical Signs and Discomfort. J Clin Med. 2022 Apr 25;11(9):2407. 3. Thulasi P and Djalilian AR. Update in Current Diagnostics and Therapeutics of Dry Eye Disease. Ophthalmology. 2017 Nov;124(11S):S27-S33. 4. Vehof J, et al. Advances, limitations and future perspectives in the diagnosis and management of dry eye in Sjögren’s syndrome. Clin Exp Rheumatol. 2020 Jul-Aug;38 Suppl 126(4):301-309. 5. Shetty R, et al. Lower Vitamin D Level and Distinct Tear Cytokine Profile Were Observed in Patients with Mild Dry Eye Signs but Exaggerated Symptoms. Transl Vis Sci Technol. 2016 Dec 14;5(6):16. 6. Shetty R, et al. Corneal Dendritic Cell Density Is Associated with Subbasal Nerve Plexus Features, Ocular Surface Disease Index, and Serum Vitamin D in Evaporative Dry Eye Disease. Biomed Res Int. 2016;2016:4369750. 7. Hu J, et al. Efficacy and safety of a vectored thermal pulsation system (Lipiflow®) in the treatment of meibomian gland dysfunction: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2022 Jan;260(1):25-39. 8. Xue AL, et al. Randomised double-masked placebo-controlled trial of the cumulative treatment efficacy profile of intense pulsed light therapy for meibomian gland dysfunction. Ocul Surf. 2020 Apr;18(2):286-297. 9. D’Souza S, et al. Clinical and Molecular Outcomes After Combined Intense Pulsed Light Therapy With Low-Level Light Therapy in Recalcitrant Evaporative Dry Eye Disease With Meibomian Gland Dysfunction. Cornea. 2022 Sep 1;41(9):1080-1087. 10. Khamar P, et al. Dysregulated Tear Fluid Nociception-Associated Factors, Corneal Dendritic Cell Density, and Vitamin D Levels in Evaporative Dry Eye. Invest Ophthalmol Vis Sci. 2019 Jun 3;60(7):2532-2542. Editors’ note: Dr. D’Souza declared no relevant financial interests.
RkJQdWJsaXNoZXIy Njk2NTg0