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Objective To evaluate the effect of full-thickness wedge resection (FTWR) on ocular surface and in vivo confocal microscopy(IVCM) findings in patients with floppy eyelid syndrome (FES).Methods The study included two groups: a surgical treatment (ST) group (26 eyes) consisting of patients who underwent FTWR surgery, and a conservative treatment (CT) group (30 eyes). Pre-treatment and post-treatment ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescein staining (CFS), IVCM findings along with the body mass index (BMI), FES grade, the presence and the treatment of obstructive sleep apnea syndrome (OSAS) were recorded and compared between the groups.Results The groups were comparable in terms of BMI, FES grade, and OSAS data. After six months, TBUT in the ST group significantly increased to 12.92 ± 1.15, compared to 8.10 ± 1.60 in the CT group (p= 0.000). The CFS and OSDI scores were significantly lower in the ST group (0.15 ± 0.37, 18.0 ± 8.3, respectively) compared to the CT group (0.90 ± 0.61, 27.3 ± 9.3, respectively) (p= 0.000). IVCM analysis revealed a significant decrease in dendritic cell count (ST: 22.0 ± 12.4, CT: 39.5 ± 15.1, p= 0.000) and nerve tortuosity (ST: 1.38 ± 0.64, CT: 2.00 ± 0.59, p= 0.000), with a significant increase in total nerve density (ST: 4.27 ± 0.83, CT: 3.57 ± 0.90, p= 0.002) in the ST group compared to the CT group after six months.Conclusion In our retrospective cohort, FTWR surgery was shown to be an effective and reliable surgical treatment for FES, improving both ocular surface and IVCM findings. Patients with moderate to severe stages of FES not responding to conservative treatment may benefit from eyelid tightening.

Background Diabetes mellitus is associated with increased risk of ocular surface diseases in elderly. We consider neutrophil CD15 as a potential marker of ocular surface damage in type II diabetes mellitus patientsAim We aimed to evaluate expression of neutrophil CD15 and correlate it with results of conjunctival impression cytology and routine objective anterior ocular surface tests (TMH, NIBUT, LLT, MGD) in T2DM patients.Materials and methods We prospectively enrolled sixty type II diabetes mellitus patients (120 eyes) into a study group. The control group included forty (80 eyes) age- and sex-matched healthy individuals. All patients underwent comprehensive ophthalmological examination, and tear meniscus height test (TMH), noninvasive tear break-up time (NIBUT), lipid layer thickness measurement (LLT), Meibomian gland dysfunction evaluation (MGD), conjunctival impression cytology (CIC) and expression of CD15.Results Abnormal Nelson's grades of squamous metaplasia (grades 2 and 3) were observed in 50% (60 eyes) of the study group, and 13.8 (11 eyes) of the control group. Fifteen patients with type II diabetes mellitus suffered from grade 3 squamous metaplasia. Nelson's grades of squamous metaplasia have shown a positive correlation with the level of CD15 expression either in the study and control groups (rs = 0.628, p = <0.0001; rs = 0.746, p< 0.0001; respectively).Conclusions The research shows significantly reduced values of routine objective ocular tests in type II diabetes mellitus patients in comparison to healthy participants older than 60 y.o. Increased CD15 in the peripheral blood is associated with the development of squamous metaplasia and may be used to evaluate the severity of ocular surface damage in type II diabetes mellitus patients.

Purpose To evaluate morphological and functional state of the meibomian glands (MG) in keratoconus patients.Methods One hundred eyes of 100 keratoconus patients and 100 eyes of 100 age-matched control subjects were included into this study. Ocular Surface Disease Index (OSDI) scores, non-invasive break up time (NIBUT), findings of meibography, staining with fluorescein of the ocular surface, tear film break-up time (TBUT), and Schirmer I test were documented in all patients’ eyes and control eyes and were compared between the groups .Results The mean TBUT and NIBUT were significantly lower, corneal staining and OSDI scores were statistically greater in the keratoconus group (p < 0.05). The mean meiboscore, partial gland, gland dropout and gland thickening scores for upper/lower eyelids were significantly greater in keratoconus patients than controls (p < 0.05). The NIBUT measurements significantly correlated with MG loss in upper/lower eyelids (p < 0.05). The severity of keratoconus seemed to correlate with meiboscore, partial gland, gland thickening scores in upper/lower eyelids.Conclusion Our data suggests that corneal ectasia in keratoconus is related with alterations in ocular surface, tear film function and MG morphology. Early screening and treatment of MG dysfunction may improve ocular surface quality and allow better disease management in keratoconus patients.

Introduction: Cystic fibrosis (CF) is the most common life-shortening recessive genetic disease in Caucasians, affecting primarily the lungs. The objective of our study was to investigate potential ophthalmologic involvement in adult patients with CF.Methods: Fifty adult patients with cystic fibrosis and 60 age- and sex-matched controls underwent complete ophthalmologic examination including tear-film Break-Up Time (BUT), Macular Thickness, and peripapillary Retinal Nerve Fiber Layer (pRNFL) thickness measurements using Spectral Domain-OCT.Results: CF patients had significantly lower nasal-inferior pRNFL thickness (median 82 IQR 67–102 vs 92.5 IQR 82–107, p= 0.005) and lower percentage of normal tear Break-Up Time (56.0% vs 96.7%, p= 0.001) than healthy controls. All CF patients with BUT <10 s were diagnosed with blepharitis at the time of our assessement. The subgroup of patients homozygous for the most common CF mutation, F508del, had lower nasal-inferior pRNFL thickness (p= 0.014) and lower percentage of normal tear Break-Up Time (p= 0.001) compared to the control group. Additional findings, present in the CF group only, were punctuate retinal hemorrhages (four patients), vessel tortuosity (four patients), snail-track degeneration, and retinal tufts (two patients without refractive error). There were no significant differences in visual acuity, refractive errors, gonioscopic findings, or intraocular pressure between the groups.Conclusions: Our study is, to the best of our knowledge, the largest ophthalmologic study of patients with cystic fibrosis. We found that CF patients had significantly decreased inferior-quadrant peripapillary retinal nerve fiber layer thickness and decreased tear-film break-up time compared to controls. We highlight the importance of careful regular ophthalmologic assessment and follow-up of these patients.

Purpose: To evaluate the effect of eyelid scrubbing with eye shampoo containing tea tree oil on dry eye disease following phacoemulsification cataract surgery.Methods: This prospective triple-blinded randomized clinical trial was performed on 62 eyes of 62 patients. Patients were randomly assigned to two groups—(1) treatment group: for 33 patients in the treatment group, artificial tears, topical steroid drops, and eye shampoos with tea tree oil and (2) for 29 patients in the control group, artificial tears, topical steroids, and eye shampoos without tea tree oil were used. In the first and second (after 1 month) follow-up visits, microscopic Demodexexamination, refraction, corrected distance visual acuity, the ocular surface disease index score (by the questionnaire), Schirmer test, tear break-up time test, and osmolarity of tears (by TearLab) were recorded in treatment and control groups.Results: The mean age of patients was 66.37 ± 8.83 (range: 37–82) years, of which 49 (79%) were female and 13 (21%) were male. The results showed a significant improvement in tear break-up time test, corrected distance visual acuity, osmolarity, and ocular surface disease index score in both groups (p< 0.05). However, the number of Demodexdecreases significantly only in the treatment group after treatment (p<0.001). Tear break-up time, osmolarity, and ocular surface disease index scores in the treatment group were significantly better than the control group (p< 0.05). However, there was no significant difference between the two groups in the pre- and post-Schirmer test results (p> 0.05).Conclusion: Eyelid scrubbing with eye shampoo containing tea tree oil is recommended for dry eye treatment after cataract surgery, especially decrease in the number of Demodex.

Purpose: To evaluate the effect of topical antiglaucomatous medications on central corneal epithelial thickness measured by anterior segment optical coherence tomography.Materials and methods: A total of 153 eyes of 153 patients using topical antiglaucomatous medications and 110 eyes of 110 control subjects were enrolled. Glaucoma type, duration of therapy, the number of drugs, and drops/day were noted in the patient group. Patients and control subjects underwent ocular examinations including Schirmer test, slit lamp examination for tear film break-up time, and anterior segment optical coherence tomography for central corneal thickness and central corneal epithelial thickness. Central corneal epithelial thickness and other data were evaluated separately with regard to glaucoma type, duration of therapy, the number of drops, and drugs in the patient group.Results: The mean ages of the patients and controls were 60.1 ± 10.8 and 58.7 ± 11.2 years, respectively. The groups were similar with regard to mean age and gender (p = 0.058, p = 0.734, respectively). The median (interquartile range) central corneal thickness was 536 (54) µm in patients and 552 (53) µm in controls (p = 0.011). The median (interquartile range) central corneal epithelial thickness of patients and controls were 56 (4) µm and 60 (8) µm, respectively (p < 0.001). The median (interquartile range) tear film break-up time and Schirmer were 12 (6) s and 10 (8) mm in patients and 16 (2) s and 18 (4) mm in controls, respectively (p < 0.001, p < 0.001). In patient group, there was no significant difference in the median central corneal thickness, central corneal epithelial thickness, and tear film break-up time in terms of glaucoma type, duration of therapy, the number of drugs, and the number of daily drops. Only the median Schirmer test was found to be statistically lower in terms of number of daily eye drops (p = 0.039).Conclusion: Using topical antiglaucomatous medications seems to affect the central corneal epithelial thickness in glaucoma patients. Central corneal epithelial thickness was thinner in glaucoma patients than controls. Anterior segment optical coherence tomography might be helpful to evaluate the effect of antiglaucomatous medications on central corneal epithelial thickness during treatment.

Purpose: The aim of this study is to evaluate the incidence, natural course, and distribution pattern of superficial punctate keratopathy and describe the changes in signs and symptoms of dry eye after cataract surgery.Setting: The setting of this study is University Hospital Rio Hortega and Instituto Universitario de Oftalmobiología Aplicada, Valladolid, Spain.Design: This is a prospective interventional study.Materials and Methods: In total, 55 eyes of 55 different patients with no history of dry eye underwent standard phacoemulsification through a 2.75-mm-wide corneal incision. We measured tear break-up time, Schirmer test I, and tear meniscus height, and recorded the Ocular Surface Disease Index score, fluorescein staining patterns, and photo documentation of the ocular surface before and 1 day, 1 week, and 1 month postoperatively. Patients were divided into two groups (with and without superficial punctate keratopathy development, 1 day postoperatively).Results: Patients (mean age: 75.75 ± 7.27 years) showed an incidence of 76.3% of superficial punctate keratopathy at 24 h. Location predominated in the center of the cornea until a week (32.7%) and then began to prevail in the inferior quadrant (21.8%) at 1 month. All dry eye tests were significantly worse after surgery. Ocular Surface Disease Index increased from 10.98 ± 5.05 to 15.87 ± 6.57 at 24 h (p< .001), to 12.80 ± 5.77 at 7 days (p< .001), and to 11.09 ± 4.63 at 1 month (p= .90). Fluorescein staining patterns got worse 24 h postoperatively with a score of 2.12 using the National Eye Institute/Industry–recommended guidelines staining grid. Average break-up time values were significantly lower at 1 day (6.61 ± 2.68),1 week (6.98 ± 2.79), and 1 month (7.05 ± 2.86) postoperatively than preoperatively (8.78 ± 2.97) (p< .001). The mean postoperative first month Schirmer test I value (8.32 ± 3.58) was significantly lower than preoperative value (9.05 ± 3.63) (p< .001).Conclusion: Phacoemulsification tends to induce short-term transitory ocular surface impairment manifesting as both signs and symptoms. Superficial punctate keratopathy distribution has a characteristic pattern evolution according to the postoperative time. Those patients with altered preoperative values are more likely to develop ocular surface disease and for longer time.

Objectives To evaluate the effect of treatment with high-dose glucocorticoids (HDG) on ocular surface parameters and in vivo confocal microscopy (IVCM) findings in patients with active thyroid eye disease (TED).Methods This study included 15 active TED patients treated with a cumulative HDG dose of 4.5g (500 mg and then 250 mg for 6 weeks each). Disease activity was assessed by the clinical activity score (CAS), Graves’ Orbitopathy-specific Quality of Life (GO-QoL) questionnaire, ocular surface disease index (OSDI), tear break-up time(T-BUT), ocular surface staining and IVCM.Results The mean follow-up time was 48.6 months. The treatment resulted in a significant improvement in the T-BUT, ocular surface staining values. In comparison to the baseline, a notable reduction in CAS, OSDI and an increase in GO-QoL were seen after one year. IVCM showed a significant decrease in the number of dendritic cells, activated keratocytes, the degree of tortuosity, there was also a significant increase in the number of basal epithelial cells and total nerves over one-year period. All of those changes remained stable during the follow-up period.Conclusion HDG treatment results in a sustained decrease in corneal inflammatory cells, an increase in tear film stability, and an improvement in disease symptoms and QoL scores for up to 4 years.

Purpose To evaluate the variations in tear parameters and meibomian gland morphology after epithelial-on (epi-on) corneal collagen cross-linking (CXL) in keratoconus (KC) patients.Methods This prospective observational study included 38 KC eyes that underwent epithelium-on CXL. Thirty-three eyes of 33 stable KC patients with no prior CXL treatment formed the KC group and 35 eyes of 35 healthy volunteers were recruited as the control group. All participants were evaluated by Schirmer I test, first and average noninvasive tear break-up time (NITBUT), ocular surface disease index (OSDI) questionnaire, and meibography scores. The CXL patients were evaluated preoperatively and at the 1st, 3rd, and 6th months, and participants without any intervention (KC and control groups) were evaluated initially, at 1st, 3rd, and 6th months.Results The KC patients had significantly lower average NITBUT, higher OSDI scores, and impaired meibomian gland morphology than healthy individuals (NITBUT(seconds): KC, 12.8(2.4–17.6), healthy group (HG), 17.1(6.8–17.6); p = 0.012, OSDI: KC, 27.5(0.0–87.5), HG, 7.5(0.0–55.0); p < 0.001, p < 0.001, respectively). A significant difference was found in Schirmer values of the CXL group at 0-1st months, first NITBUT values at 1–6 months, and average NITBUT values at 1–3 and 1–6 months (p = 0.003, p = 0.001, p = 0.003, p = 0.001, respectively). All meibography parameters remained unchanged after CXL over a 6-month follow-up compared to initial measurements.Conclusions Even though the KC patients had lower NITBUT, higher OSDI scores, and increased meibomian gland disfunction, the CXL treatment did not significantly affect tear quantity, dry eye symptoms, and meibomian gland morphology.

Purpose Compare 0.30% sodium hyaluronate (0.30%HA) ocular gel with 0.18%HA eye drops in terms of improvement of ocular signs and symptoms, in patients with moderate to severe dry eye disease (DED).Methods This was a multicentric, randomized, investigator-masked, non-inferiority, comparative study conducted over 84 days. Three visits were scheduled, testing fluorescein corneal and conjunctival staining (Oxford and Van Bijsterveld scores), tear film break-up time (TBUT), Schirmer test, DED symptoms, 5-Item-Dry-Eye-Questionnaire (5-DEQ), patient and investigator satisfaction and frequency of instillation.Results At Day 35 (D35) and Day 84 (D84), both groups (n = 35 each) had a significant improvement in corneal staining (p < 0.001) with no inter-group difference. Van Bijsterveld score improved earlier (D35) for 0.30%HA suggesting a faster effect on conjunctival epithelium healing. There was no difference between the two concentrations in terms of TBUT or Schirmer improvements; however, the Schirmer test increase was only significant for 0.30%HA at D35 (p = 0.040). At D35 and D84, both groups showed similar improvements of DED symptoms and DEQ-5 score. Furthermore, treatment satisfaction was similar for the 2 formulations suggesting that daily use of 0.30%HA do not cause gel-related blurred vision disturbances. Frequency of instillation was similar for both groups.Conclusion Our study demonstrates the non-inferiority of 0.30%HA gel compared to 0.18%HA solution in patients with moderate to severe DED. Because of its gel formulation and higher HA concentration providing prolonged comfort without causing visual disturbances, 0.30%HA gel might be adapted for bedtime use or during the day in more severe conditions.

Objective To investigate the effect of eyelid spasm on corneal and tear film characteristics in patients with hemifacial spasm (HFS) and compare these data with those of the contralateral eyes of the same patients.Methods This prospective study is comprised of 64 eyes of 32 HFS patients, 32 eyes on the spasm side (Group 1) and 32 contralateral eyes (Group 2). Corneal tomographic analyses were performed; corneal power of flat axis (K1) and steep axis (K2), astigmatism and thinnest pachymetry; anterior, posterior and total corneal aberrometry [spherical aberration (SA), vertical coma (vcoma), horizontal coma (hcoma), total higher order aberration (THOA) and total RMS], and corneal densitometry values were evaluated and compared between groups. Tear meniscus height and depth (TMH, TMD) were measured using anterior segment optic coherence tomography. Tear function tests including TMH and TMD, the Schirmer I test, and tear break-up time (TBUT) were compared between the groups.Results K1, K2, astigmatism and corneal densitometry values were similar between groups (p > 0.05). Thinnest pachymetry values were significantly thinner on the spasm side (p = 0.040). Anterior and total corneal SA and RMS were significantly higher on the spasm side (p = 0.032, p = 0.005; p = 0.015, p = 0.006, respectively). TMH, TMD and TBUT were significantly lower in Group 1 (p = 0.01, p = 0.02 and p = 0.03, respectively). Schirmer I test values were similar between groups (p > 0.05).Conclusion In HFS patients, there are changes in corneal parameters and tear film in the eye on the spasm side compared to unaffected eye.

Purpose To evaluate the effect of wearing facemasks on dry eye symptoms and on the tear film while comparing surgical face masks to N95 particulate respirators.Methods A prospective observational study was conducted at Ain Shams University Hospitals in the period from September 2020 to January 2021. Two hundred volunteers were recruited, and the daily number of hours spent by each participant wearing a facemask was recorded. Recruits were divided into two groups: 100 volunteers were allocated to Group A to use the surgical mask, and 100 participants to Group B to use the N95 particulate respirator. The tear film parameters were assessed at baseline by answering the Ocular Surface Disease Index (OSDI) questionnaire and performing tear break-up time (TBUT), corneal fluorescein staining, and Schirmer-I test Subjects then wore a facemask for 60 min and then the tear film parameters were reassessed by repeating TBUT, corneal staining and Schirmer-I testResults Facemask use for 60 min significantly worsened all tear film parameters in both groups (P-value <0.0001). The deterioration was significantly larger in Group A subjects (P < 0.0001). The daily number of hours spent wearing a facemask correlated strongly with the OSDI and corneal staining. There was a strong negative correlation between the daily number of hours spent wearing a facemask and Schirmer test, and a weak negative correlation with TBUT.Conclusions Wearing facemasks during the COVID-19 pandemic is a risk factor for worsening tear film parameters. This deterioration is significantly greater with surgical masks than with N95 particulate respirators and increases with the duration of facemask use.

Purpose: Preservatives in glaucoma medications have been associated with ocular toxicity. We compared ocular signs and symptoms in patients with open-angle glaucoma or ocular hypertension treated in monotherapy with preserved or preservative-free prostaglandin analogues.Methods: Observational cross-sectional clinical study in real life. 82 patients treated for at least 6 months with prostaglandin analogue were assessed for intraocular pressure, ocular symptoms and ocular signs including conjunctival hyperaemia, tear break-up time and tear meniscus height measured using objective and non-invasive methods (OCULUS Keratograph 5M). Patients presenting with symptoms of ocular toxicity with preserved prostaglandin analogues were switched to preservative-free latanoprost, and a second assessment was processed 6 months after.Results: At inclusion, 30 (36.6%) patients were treated with preservative-free latanoprost, 25 (30.5%) with preserved latanoprost, 16 (19.5%) with preserved travoprost and 11 (13.4%) with preserved bimatoprost. Patients treated with preservative-free latanoprost reported significantly less ocular symptoms upon instillation (mainly burning) and between instillations than patients treated with preserved prostaglandin analogues. The mean conjunctival hyperaemia (limbal + bulbar) was significantly lower with preservative-free latanoprost (2.08 ± 0.55) compared to preserved latanoprost (2.50 ± 0.7, p = 0.0085), preserved travoprost (2.67 ± 0.82, p = 0.0083) and preserved bimatoprost (2.68 ± 0.67, p = 0.0041). There were no relevant between-group differences in mean tear meniscus height and break-up time. Ocular symptoms and conjunctival hyperaemia improved when preserved prostaglandin analogues were switched to preservative-free latanoprost for 6 months while intraocular pressure reduction was maintained.Conclusion: Overall, this study suggests a better subjective and objective ocular tolerance when patients were treated with preservative-free latanoprost than with other preserved prostaglandin analogues monotherapy. Switching to preservative-free latanoprost maintained intraocular pressure at the same level as preservative prostaglandin analogue, but improved ocular surface tolerance.

Purpose: To assess tolerability and efficacy following a switch from benzalkonium chloride–latanoprost to preservative-free latanoprost in patients with glaucoma or ocular hypertension.Methods: A total of 140 patients with glaucoma or ocular hypertension controlled with benzalkonium chloride-latanoprost for at least 3 months were switched to treatment with preservative-free latanoprost. Assessments were made on days 15, 45, and 90 (D15, D45, and D90) and included best-corrected visual acuity, intraocular pressure, slit lamp examination, fluorescein staining, tear film break-up time, patient symptom evaluation, and subjective estimation of tolerability.Results: Mean best-corrected visual acuity remained unchanged during the study. Mean intraocular pressure compared with baseline (D0) remained stable throughout the study (D0, 15.9 mmHg (standard deviation = 2.6); D90, 15.3 mmHg (standard deviation = 2.4); p < 0.006). Tear film break-up time improved or remained unchanged relative to baseline in 92% of patients at D45 and in 93% at D90. Moderate-to-severe conjunctival hyperemia was seen in 56.8% of patients at D0, but this figure decreased to 13.7%, 2.2%, and 1.6% at D15, D45, and D90, respectively. Subjective assessment of tolerability (0–10 scale) indicated improvement with change of therapy (mean score: 5.3 (standard deviation = 2.2) at D0 versus 1.9 (standard deviation = 1.7) at D90; p < 0.0001).Conclusion: Preservative-free latanoprost has at least the same intraocular pressure-lowering efficacy as benzalkonium chloride–latanoprost, with a better tolerability profile. This may translate into greater control of treatment and improved quality of life.

Purpose: To investigate the ocular physiologic changes and subjective symptoms of wearing multiple-pinhole glasses in subjects with presbyopia.Methods: This prospective study included 32 eligible subjects with presbyopia. Objective ocular functions and a survey of ocular discomfort were performed at baseline. All participants underwent the same examinations after reading while wearing the pinhole glasses and not wearing these glasses at a 1-week interval in random order.Results: The pinhole glasses improved uncorrected distance and near visual acuity in presbyopia. These glasses also required 15% less accommodative power over the near stimulus of 25 cm than did eyes without pinholes. Compared to reading without pinhole glasses, reading with pinhole glasses led to the following changes: increase in monocular near point of accommodation from 4.39 ± 0.78 diopter (D) to 5.19 ± 1.12 D, increase in depth of focus from 1.42 ± 0.44 D to 2.00 ± 0.33 D, and increase in amplitude of fusional convergence from 13.38 ± 6.88 prism D to 21.62 ± 10.00 prism D. In contrast, the reading speed decreased, inter-blink interval increased, tear break-up time shortened, and subjective ophthalmic symptoms worsened with pinhole glasses compared to without.Conclusion: In presbyopia, pinhole glasses improve visual acuity and accommodation-related parameters by pseudo-accommodation and the pinhole effect. However, the low legibility, increased inter-blink interval, and shortened break-up time of pinhole glasses cause an uncomfortable feeling and excessive eye fatigue. Pinhole glasses have strengths and limitations that must be considered to provide appropriate guidance in patients with presbyopia. Clinical trial registration was done at www.ClinicalTrials.gov(identifier: NCT02722291).

Purpose: To evaluate ocular surface alterations and characteristics of corneal basal epithelium and subbasal nerves in patients with myasthenia gravis.Materials and methods: Myasthenia gravis patients (n = 21) and healthy controls (n = 20) were enrolled. All participants underwent ocular surface testing in the following order: tear break-up time, lissamine green staining, Schirmer I test with anesthesia, and Ocular Surface Disease Index questionnaire. The Cochet-Bonnet esthesiometer was used to measure corneal sensitivity. Basal epithelial cells and subbasal nerves were evaluated using in vivo confocal microscopy.Results: Myasthenia gravis patients had higher Ocular Surface Disease Index score (13.9 ± 15.0 vs 1.4 ± 2.2, p < 0.001) and lissamine green staining score (0.6 ± 0.4 vs 0.2 ± 0.4, p = 0.007). Break-up time score (9.3 ± 3.0 vs 9.9 ± 1.9, p = 0.481) and Schirmer I test score (16.5 ± 9.2 vs 19.3 ± 8.4, p = 0.323) did not differ significantly. Corneal sensation was 0.4 g/mm2in all eyes. Patients with myasthenia gravis had lower basal epithelial cell density (3775.7 ± 938.1 vs 4983.1 ± 608.5, p < 0.001) and total nerve density (1956.1 ± 373.3 vs 2277.9 ± 405.0, p = 0.012) and higher subbasal nerve tortuosity (1.9 ± 0.8 vs 1.6 ± 0.7, p = 0.007) than controls. A significant increase in Ocular Surface Disease Index scores was found with decreasing basal epithelial cell density (rho = −0.518, p = 0.001). There was a significantly moderate negative correlation between the duration of myasthenia gravis and the number of corneal nerves (rho = −0.497, p = 0.022).Conclusion: Significant alterations of basal epithelial cells and subbasal nerves were demonstrated in myasthenia gravis patients although there was no difference of corneal sensitivity between myasthenia gravis patients and healthy controls. Thus, it should be borne in mind that myasthenia gravis patients deserve further evaluation with regard to ocular surface disease.

Purpose: To evaluate the efficacy and safety between two generic prostaglandins Lataz–Xalaprost (Greece) and the corresponding original drops (Xalatan®).Material and methods: In this prospective randomized study, 60 patients diagnosed with open-angle glaucoma or ocular hypertension were enrolled, who had never received antiglaucoma treatment. Subjects were divided randomly into three groups (Xalatan, Lataz, and Xalaprost groups) and they were studied over 16 weeks. At each visit, the mean applanation tonometry values and tear break-up time were measured. The Ocular Surface Disease Index questionnaire was used to evaluate patient’s symptoms.Results: There was a statistically significant difference (p < 0.001) in the mean values of the intraocular pressure between the baseline and the last visit (Xalatan group: from 23.11 ± 1.61 mmHg to 15.81 ± 1.22 mmHg, Lataz group: from 23.26 ± 1.33 mmHg to 15.80 ± 1.47 mmHg, and Xalaprost group: from 23.08 ± 1.45 mmHg to 16.08 ± 1.38 mmHg). Both generic eye drops showed mean percentage intraocular pressure reduction comparable to the standards of prostaglandin analogues (Xalatan: 31.57%, Lataz: 32.06%, and Xalaprost: 30.34%). Xalatan reduced the tear break-up time less, followed by Lataz and then by Xalaprost (Xalatan: from 8.5 to 8 s, Lataz: from 8.2 to 7.4 s, and Xalaprost: from 8.7 to 7.7 s). Xalatan presented the best safety profile, followed by Lataz and least was Xalaprost, according to Ocular Surface Disease Index questionnaire’s results.Conclusion: No significant difference was recorded in the effectiveness of each generic prostaglandin compared to the original. Furthermore, no patient had to change medication. The differences that arose in the safety profile of the three eye drops suggest a prompt closer initial monitoring of patients who are administered generic eye drops.

Purpose: This study aimed to analyze the changes in meibomian glands (MGs) and tear film layer over time in patients taking systemic isotretinoin treatment.Methods: Patients who received systemic isotretinoin treatment between 4 and 8 months were prospectively followed up. In addition to full ophthalmologic examination, MG dysfunction (MGD), noncontact meibography, noninvasive and invasive tear break-up time (TBUT), ocular surface disease index (OSDI), corneal staining, and eyelid margin abnormality scores were recorded before, during, and after treatment.Results: A total of 88 eyes of 88 patients were included in the study. The right eyes of all the patients were included. The mean age of the patients was 21 ± 2.9 years. Of the 88 patients, 70 (79.6%) were females and 18 (20.4%) were males. Before the treatment, MGD, noncontact meibography, first noninvasive TBUT, mean noninvasive TBUT, invasive TBUT, OSDI, corneal staining, and eyelid margin abnormality scores were 0.29 ± 0.45, 4.93 ± 3.50, 13.78 ± 3.89 s, 14.47 ± 3.09 s, 12.96 ± 3.61 s, 0.54 ± 1.00, 0.04 ± 0.20, and 0.09 ± 0.28, respectively. Twelve months after the end of treatment, the scores were 0.97 ± 0.87 (p< 0.001), 9.62 ± 3.89 (p< 0.001), 11.24 ± 3.52 s (p< 0.001), 12.34 ± 3.02 s (p< 0.001), 11.31 ± 2.90 s (p< 0.001), 1.90 ± 2.44 (p< 0.001), 0.20 ± 0.40 (p< 0.001), and 0.56 ± 0.49 (p< 0.001), respectively.Conclusion: Systemic isotretinoin treatment causes morphological changes in the MGs. However, this treatment may negatively affect the tear film layer of patients. Some of these changes may persist for a long time even if the treatment is discontinued.

Background: To investigate aqueous and lipid layers of the tear film as well as meibomian gland structure by meibography in psoriatic patients in the Iranian population.Methods: This case-control study was conducted on 31 psoriasis patients and 31 controls in Birjand University of Medical Sciences in 2018. The sampling method was available from the date of approval of the proposal in the Ethics Committee until it reached the sample size. After entering the study, patients were examined individually with a slit lamp. Then, Ocular Surface Disease Index (OSDI) score assessment, Schirmer test 1, lacrimal measurement with SM tube, tear break-up time (TBUT), and meibomian glands imaging by SBM Sistemi were done. Finally, the obtained data were entered into SPSS 15 software and analyzed at a significant level of less than 0.05.Results: The two groups were matched according to age and gender (p= 0.39 and p= 0.80; respectively). With the exception of the SM Tube score, the mean of all tear film and meibomian glands functional and structural parameters including Schirmer test 1, TBUT, and meibography were significantly different between patients and control groups. Moreover, the proportion of abnormal OSDI (OSDI ⩾ 13) and the dry eye was significantly higher in psoriasis patients.Conclusions: Psoriasis is associated with dry eye as well as meibomian glands atrophy and dysfunction.

Purpose: To analyze the relation between Meibomian gland dysfunction, dry eye, and sarcoidosis.Materials and Methods: Twenty eyes of 10 sarcoidosis patients (Group 1) and 20 left eyes of 20 age-sex matched healthy volunteers (Group 2) were included. Presence of dry eye was evaluated with Schirmer 1 test, tear film break-up time (T-BUT), Oxford scale scoring, Ocular Surface Disease Index (OSDI) score assessments. A slit-lamp biomicroscope infrared filter (Topcon, SL-D701, IJssel, The Netherlands) was used to evaluate Meibomian glands. The drop-out ratio according to meibography was scored for each eyelid from grade 0 (no loss) through grade 3 (lost area >2/3 of the total Meibomian gland area).Results: Among dry eye tests mean Schirmer 1 and T-BUT values were lower and OSDI score was higher in Group 1 compared to Group 2 and the differences were statistically significant (p= 0.017, p= 0.039, p= 0.003, respectively). In addition, the upper, lower and total meiboscores were statistically significantly higher in Group 1 (p= 0.047, p= 0.003, p= 0.005, respectively).Conclusion: A significantly higher presence of dry eye and Meibomian gland drop out ratios was detected in sarcoidosis patients. It is important to monitor sarcoidosis patients for dry eye and Meibomian gland dysfunction and when detected, to treat adequately to prevent ocular surface damage.

Purpose: To evaluate the tear parameters, meibomian glands and lid margin and tarsal conjunctival impression cytology in patients with conjunctivochalasis (CCH).Methods: The study included 57 patients diagnosed with CCH and 35 healthy volunteers. Tear break-up time (TBUT) was measured and Schirmer test was performed. Meibomian gland morphologies, dropout rates, and meiboscores were evaluated using meibography. Finally, impression cytology samples were taken by pressing the impression filters on the lower lid margin and lower tarsal conjunctiva. The samples were evaluated according to the Nelson grading system.Results: Schirmer test was longer and TBUT was shorter in the study group (p= 0.035 and p< 0.001, respectively). The median of meibomian gland dropout rate was 33.45% (Interquartile range [IQR]; 23.17%–49.75%) and 18.80% (IQR; 12.35%–26.50%) in the study and control groups, respectively (p< 0.001). There was no significant difference in terms of lid-margin cytology between the two groups (p= 0.481). In tarsal conjunctiva cytology, the median value of Nelson grade of the study group was 2 (IQR; 1–2) and that of the control group was 1 (IQR; 1–2) (p= 0.040). When Nelson grade-2 and above was accepted as the pathological limit, it was found that 27.5% of the study group and 15.2% of the control group showed pathological findings (p= 0.204).Conclusions: In patients with CCH, damage occurs in the tarsal conjunctiva with the effects of redundant conjunctival folds. In these patients, atrophy occurs in the meibomian glands and tear stability is impaired. Therefore, CCH should not be overlooked in clinical practice.

Purpose: To compare the effect of topical application of tacrolimus 0.03% eyedrops versus cyclosporine 0.05% in Sjogren syndrome subjects with severe dry eyes.Design: A prospective single-blinded simply randomized controlled study.Methodology: 60 Sjogren patients were randomized into Group A: 30 patients were instructed to put tacrolimus 0.03% eyedrops in one eye for 6 months and placebo eyedrops in the other eye, (N= 30, 44.9 ± 12.58 years). Group B: 30 patients were instructed to put cyclosporine 0.05% eyedrops in one eye for 6 months and placebo eyedrops in the other eye (N= 30, 49.4 ± 12.92 years). Main outcome measures: Patients were evaluated at day 0, 90, and 180 for Ocular Surface Disease Index Questionnaire (OSDI), frequency of use of artificial tears, average fluorescein tear break up time (TBUT), ocular surface staining scores, Schirmer I test, meibum quality, and expressibility scores.Results: Upon comparing both eyedrops, the mean value of OSDI decrease was 38.25 ± 18.29% versus 31.69 ± 18.57% (p-value 0.09), SICCA score decrease was 2.97 ± 1.92 versus 2.27 ± 2.02 (p-value 0.124) the decrease in artificial tear substitute use was 3.90 ± 2.22 versus 3.63 ± 1.92 (p-value 0.616), increase in Schirmer I values were 4.10 ± 4.21 and 4.26 ± 2.00 (p-value 0.590) in eyes treated with tacrolimus and cyclosporine respectively. Neither of them affected meibum quality or expressibility scores.Conclusion: Both tacrolimus and cyclosporine significantly improved patient symptoms, frequency of artificial tears use and ocular surface staining compared to placebo-controlled eyes. However, no significant difference regarding the efficacy of both eyedrops at the end of 6 months treatment of severe dry eyes of Sjögren syndrome patients.Trial registration: ClinicalTrials.gov. Identifier: NCT03865888.

Purpose: To describe the clinical course of a case of bilateral Salzmann nodular degeneration (SND) treated with superficial keratectomy (SK) followed by intense pulsed light (IPL) for the treatment of coexisting meibomian gland dysfunction (MGD).Case description: A 54-year-old man who presented to us complaining of progressive blurred vision associated with foreign body sensation in both eyes because of SND and coexisting MGD. In view of symptoms and visual acuity (VA) deterioration, bilateral SK was performed. Two months after SK, IPL treatment to the face and meibomian glandexpression (MGX) using the E-eye device (E-SWIN, Paris) on days 0, 15, and 45, were performed in both eyes with the aim to avoid recurrence and/or progression of MGD. One year after SK, the patient was asymptomatic and VA was 20/20 in both eyes; however because of worsening of non-invasive tear film break-up time measured on Sirius®Scheimpflug tomograph, IPL and MGX were promptly repeated and scheduled every 6 months.Conclusion: In our case, IPL was a safe and effective option to control MGD in a patient with SND requiring SK with no observed recurrence of SND 2 years after surgery.

Purpose To describe and compare ocular surface changes in patients with type 2 diabetes treated with either oral antidiabetic drugs (OAD) or insulin.Methods Forty eyes of 20 patients treated with OAD, 40 eyes of 20 patients treated with insulin, and 10 nondiabetic controls seen at Ministry of Health Ankara Educational and Research Hospital, 1stEye Clinic, were studied. All subjects underwent routine ophthalmic examinations, Schirmer test, tear film break-up time analysis, and conjunctival impression cytologic analysis. Patients treated with OAD or insulin and a control group were compared for tear function parameters, goblet cell density, and squamous metaplasia grade. The relation between status of retinopathy and ocular surface disorder and serum HbA1c levels of diabetic patients were also noted.Results The tear film break-up time values were significantly lower in patients treated with OAD (p<0.05). There was no statistically significant difference in Schirmer test results of the 3 groups. Goblet cell density and squamous metaplasia grade were similar in all groups. The median grade was grade 1, in which epithelial cells are slightly larger, more polygonal, have eosinophilic staining cytoplasm, and goblet cells are decreased in number. Status of retinopathy did not seem to relate to ocular surface disorder. The serum HbA1c level of diabetic patients treated with insulin or OAD was similar (p>0.05).Conclusions Precorneal tear film stability was worse in patients treated with OAD; however, impression cytology analysis and Schirmer test results were similar in all groups.

Purpose To evaluate ocular surface changes in long-term silicone hydrogel contact lens wearers.Methods Thirty patients were included in this study. Twenty patients (40 eyes) using contact lenses constituted group 1 and 10 (20 eyes) volunteers constituted group 2. The duration of average contact lens usage was 7.74±3.3 years. Ocular surface was evaluated by surface staining, tear film break-up time (TBUT), Schirmer I test, and conjunctival impression cytology with color-coded mapping technique and by the Ocular Surface Disease Index (OSDI).Results The mean break-up time was lower and staining scores were higher in group 1 (p<0.001) but Schirmer values were not significantly different from group 2 (p>0.05). The mean OSDI score was 34.59±11.93 to 19.28±6.7 in group 1 and 2. Increased metaplastic predominant changes of grade II and III were observed in the interpalpebral and perilimbal areas in group 1. Significant correlations were observed in TBUT, cornea staining, and grade II to grade III metaplasia ratios between duration of the lens usage and contact lens wear time in a day.Conclusions Silicone hydrogel lenses produce significant changes on tear film and impression cytology of the ocular surface in long-term use.

Purpose. This study evaluated the efficacy of topical cyclosporine A 0.05% treatment with impression cytology in dry eye patients.Methods. Forty eyes of 40 patients with dry eye were included. Schirmer, tear break-up time, and Ocular Surface Disease Index (OSDI) scores and goblet cell densities were noted before and after 6 months of topical cyclosporine A treatment. Patients were graded clinically and biomicroscopically as follows: grade 1, 12 patients; grade 2, 18; and grade 3, 10 patients.Results. Mean age was 57.1±11.8 (23.0–80.0) years. A total of 36 (90%) of the patients were female and 4 (10%) were male. Mean Schirmer test value was 3.2±1.6 (0.0–8.0) mm in the beginning and was 8.4±4.3 (1.0–19.0) mm after 6 months of cyclosporine A topical treatment (p=0.00). At the first visit, mean tear break-up time was 4.4±1.8 (2.0–8.0) seconds. It increased to 11.8±4.8 (2.0–20.0) seconds at the end of the sixth month (p=0.00). Mean clinical grading was 1.9±0.8 (1.0–3.0) and this value regressed to 0.8±1.2 (0.0–3.0) after the treatment (p=0.00). Mean OSDI score was 30.0±11.7 (9.0–50.0) before the treatment and 21.3±11.0 (4.0–47.0) after the treatment (p=0.00). Mean goblet cell density of all cases was 12.3±8.7 before the treatment (2.0–28.0). It increased to 33.0±25.4 (6–70) after the treatment (p=0.04).Conclusions. Topical cyclosporine A treatment is effective in grade 1 and grade 2 dry eye patients but results are poor in grade 3 patients.

Purpose This clinical investigation compared the performance and safety of Eyestil Plus® (SIFI) and Vismed Multi® (TRB Chemedica) for reducing keratitis lesions in moderate-to-severe dry eye disease (DED) patients.Materials and methods This was a randomised, double-blind, multicentre investigation. 96 adults (>18 years of age) with moderate-to-severe DED received Eyestil Plus® (N= 48) or Vismed Multi® (n= 48) 6 times daily for 3 months. The primary objective clinical performance after 1 month as global corneal and conjunctival staining scores. The secondary objectives were clinical performance after 3 months, tear film stability (tear break up time (TBUT), tear production (Schirmer test), patient-reported outcomes (PROs), investigator satisfaction, and safety.Results 96 participants were randomised to receive the clinical investigations’ treatments, 82.3% of them were female and their mean age was 65.8 years. The non-inferiority of Eyestil Plus® for moderate-to-severe DED was demonstrated at 1 month. No statistical difference was found for any of the study's objectives: change at 1 and 3 months of the global corneal and conjunctival staining score (p-value = 0.506 and 0.661, respectively), change at 1 and 3 months (p-value = 0.538 and 0.302) for TBUT test; change at 3 months for Schirmer test (p-value = 0.540). There were no changes for PROs either. Investigator satisfaction was high for both products. 16.6% of the participants experienced adverse events.Conclusion This clinical investigation showed the non-inferiority of Eyestil Plus® compared to Vismed Multi® regarding performance and safety in a moderate-to-severe DED population.

Purpose Study the effect on the tear film in blepharospasm (BEB), facial hemispasm (FH), or aberrant regeneration (AR) treated with Botulinum Toxin (BTX-A).Methods A prospective study was used to evaluate the tear film in patients with BEB, FH, or AR treated with BTX-A. Schirmer tests, break-up time (BUT), optical coherence tomography (OCT) meniscus measurement, the Ocular Surface Disease Index (OSDI) questionnaire, and Oxford scale were documented before; 1 month after; and 3 months after BTX-A treatment. Comparisons were made with the Friedman test and Wilcoxon matched-pairs signed rank test was used. A p-value <0.05 was considered statistically significant.Results A total of 35 eyes from 27 patients were included. The mean patient age was 66.81 ± 12.94 years and 18 (66.7%) were female. Ten (37%) patients had BEB, six (22.2%) had FH, and 11 (40.74%) had AR. BTX-A improved the lid spasms. One month after BTX-A, Schirmer tests showed slight increments (Schirmer 1 p= 0.009; Schirmer 2 p= 0.05) and at 3 months they became similar to pre-treatment (p= 0.5). The BUT test was not significantly different at 1 month (p= 0.450) or at 3 months. On OCT 1 month after BTX-A, there was an increase in tear meniscus area (p= 0.004), height (p= 0.007), and depth (p= 0.004), and at 3 months the measurements also became similar to the pre-BTX-A values. No significant changes in the OSDI (p= 0.717) and Oxford scale (p= 0.255).Conclusion OCT is a good tool to detect the increase in tear meniscus after periocular BTX-A in BEB, FH, and AR.