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Purpose To explore objective visual quality in dry eye diseases (DED) and the correlation between corneal nerves and objective visual quality. Methods Ninety-eight eyes of 49 patients with DED were included. Each patient was evaluated with the ocular surface disease index (OSDI), eyelid margin signs and meibomian gland assessments; corneal staining; tear film breakup time (TBUT); tear meniscus height (TMH); in vivo confocal microscopic (IVCM); objective visual quality including the objective scatter index (OSI), mean objective scattering index (mOSI), modulation transfer function (MTF) cutoff value and Strehl ratio. Results A significant correlation was found between the OSDI and mOSI (r = 0.422, p = 0.005), MTF cutoff value (r = − 0.355, p = 0.020), and Strehl ratio (r = − 0.446, p = 0.003). The OSI was significantly correlated with TBUTf (r = − 0.213, p = 0.042). The mOSI, MTF cutoff value, Strehl ratio were correlated with eyelid margin signs and meibomian assessments. Additionally, there was a statistically significant correlation between corneal nerve length and the mOSI (r = − 0.239, p = 0.037), OSI (r = − 0.294, p = 0.028), MTF cutoff value(r = 0.282, p = 0.012), and Strehl ratio (r = 0.299, p = 0.008). Conclusions Our study explored that objective visual quality was correlated with clinical symptoms and signs in DED patients. Furthermore, for the first time, our study explored the relationship between corneal nerves and objective visual quality and discovered that longer and wider corneal nerves were associated with better objective visual quality, which suggested that nerve changes may be a factor that related to poor visual quality in DED patients.

Purpose. Our study aimed to evaluate the efficiency of intense pulsed light (IPL) combined with meibomian gland expression (MGX) in treating meibomian gland dysfunction (MGD). Methods. This study was a prospective interventional study. A total of 53 patients were included in the study and received a series of three treatments at an interval of 3-4 weeks. Follow-up examinations were completed 4 weeks after the last treatment. The Ocular Surface Disease Index (OSDI) questionnaire, tear meniscus height (TMH), tear break-up time (TBUT), slit-lamp examinations, and in vivo confocal microscopy (IVCM) were recorded before and after treatment. Additionally, an artificial intelligence automated software program was applied in our study for corneal nerve analysis. Results. The OSDI score was significantly reduced after the IPL treatment compared with baseline (P<0.001). Meibomian gland assessment scores, including meibum quality and expressibility, eyelid margin abnormalities, and corneal staining, significantly decreased after treatment (P<0.05). Moreover, the corneal nerve fiber length (CNFL) significantly increased after the treatment (P<0.001). Conclusion. Intense pulsed light (IPL) combined with MGX is an effective treatment for MGD, and neurotrophism could be one of the mechanisms of IPL.

An 84-year-old woman underwent cataract surgery. In 3 weeks, the right eye presented with blurred vision, corneal irritation and photophobia. After 5 weeks, symptoms in the right eye worsened and ganciclovir was prescribed. Based on clinical findings, viral keratitis was suspected; real-time PCR (RT-PCR) assay of tear samples from the right eye was performed. Thereafter 1 week, the left eye also exhibited similar symptoms. The RT-PCR was performed using a sample from the left eye; the results suggested the presence of Epstein–Barr virus and cytomegalovirus. A combination of confocal microscopy and RT-PCR assay of tear samples can supplement slit-lamp observation and help diagnose atypical and refractory postcataract surgery viral keratitis.

Purpose. To comparatively evaluate the safety and satisfaction of bandage contact lens (BCL) and eye patching in patients after cataract surgery. Methods. Sixteen (32 eyes) patients who planned to undergo bilateral cataract surgery were recruited. The two eyes of each patient were randomly divided into 2 groups. Group A and Group B were instructed to wear BCLs immediately at the end of the surgery until one week and eye patch immediately after surgery until one day, respectively. Visual analog scales of ten specific symptoms, Visual Function Index (VF-14) questionnaire, and best-corrected visual acuity (BCVA) were conducted on the first day before the surgery and Day 1 and Day 7 after surgery. Oculus keratography was conducted on the first day before surgery and on Day 7. Patient satisfaction was determined on Day 1. Moreover, bacterial species in the conjunctival sac, meibomian gland secretions, and BCLs were subsequently identified using 16S rRNA gene sequencing. Results. The patient satisfaction scores of Group A were higher than Group B. Group A were more motivated to choose the same treatment and were more likely to recommend BCLs to others. No statistically significant differences were found in bacterial culture positivity between the groups. The differences in ocular signs and symptoms between the two groups were not statistically significant. There were no significant differences in the BCVA and VF-14 between the groups at any time point. Conclusions. BCLs could be safely and effectively used in patients after cataract surgery.

Purpose: To improve the medical management system and the quality of medical treatment, this study aimed to assess patient satisfaction related to an ocular surface individualized medical program for dry eye, and identified patient needs that should be addressed in future. Methods: We enrolled 166 patients from the dry eye clinic at the Peking University Third Hospital from December 2017 to May 2019. An investigator followed up with all patients by telephone 2 months after the first assessment of overall patient satisfaction, expectations, and experiences. We determined patient satisfaction using a questionnaire and analyzed the results. Multivariate linear regression analysis was used to assess the predictors of overall patient satisfaction. Results: The overall patient satisfaction with the ocular surface individualized medical program skewed toward a positive assessment. Ten variables were significantly associated with overall patient satisfaction: two involving fulfilment of expectations, seven involving patient-reported experiences, and one involving socio-demographics. The most important predictor of overall patient satisfaction was patient-reported experiences with the treatment outcome (β = 0.281, p Conclusion: Overall, the ocular surface individualized medical program is effective and is able to achieve satisfaction for most patients. The examination procedures and environment require improvements, and treatment must be made more patient-centric to improve satisfaction.

Purpose The purpose of this study was to establish a deep learning model for automated sub-basal corneal nerve fiber (CNF) segmentation and evaluation with in vivo confocal microscopy (IVCM). Methods A corneal nerve segmentation network (CNS-Net) was established with convolutional neural networks based on a deep learning algorithm for sub-basal corneal nerve segmentation and evaluation. CNS-Net was trained with 552 and tested on 139 labeled IVCM images as supervision information collected from July 2017 to December 2018 in Peking University Third Hospital. These images were labeled by three senior ophthalmologists with ImageJ software and then considered ground truth. The areas under the receiver operating characteristic curves (AUCs), mean average precision (mAP), sensitivity, and specificity were applied to evaluate the efficiency of corneal nerve segmentation. The relative deviation ratio (RDR) was leveraged to evaluate the accuracy of the corneal nerve fiber length (CNFL) evaluation task. Results The model achieved an AUC of 0.96 (95% confidence interval [CI] = 0.935-0.983) and an mAP of 94% with minimum dice coefficient loss at 0.12. For our dataset, the sensitivity was 96% and specificity was 75% in the CNF segmentation task, and an RDR of 16% was reported in the CNFL evaluation task. Moreover, the model was able to segment and evaluate as many as 32 images per second, much faster than skilled ophthalmologists. Conclusions We established a deep learning model, CNS-Net, which demonstrated a high accuracy and fast speed in sub-basal corneal nerve segmentation with IVCM. The results highlight the potential of the system in assisting clinical practice for corneal nerves segmentation and evaluation. Translational relevance The deep learning model for IVCM images may enable rapid segmentation and evaluation of the corneal nerve and may provide the basis for the diagnosis and treatment of ocular surface diseases associated with corneal nerves.

PURPOSE To compare the efficacy of intense pulsed light (IPL) and near-infrared light (NIL) treatments in alleviating symptoms and signs of dry eye disease (DED). METHODS Patients diagnosed with DED at the Peking University Third Hospital Eye Center from January 2019 to October 2019 were randomized to undergo either NIL therapy combined with meibomian gland expression (MGX; NIL Group) or IPL combined with MGX (IPL Group). Treatments were performed three times at 1-month intervals. DED signs and symptoms were evaluated before every treatment. We compared the clinical improvement within and between the groups. Additional comparisons were made according to the meibomian gland (MG) dropout grade. RESULTS A total of 260 eyes of 130 patients (mean age, 49.68 ± 18.01 years) were included. The dryness and total symptom scores and the MG expressibility and secretion quality (upper and lower eyelids) significantly improved after the three treatments in both groups (p

Purpose. To assess the effects of oral vitamin B1 and mecobalamin on dry eye disease (DED) and patient satisfaction with treatment. Methods. In this randomized controlled study, DED patients were divided into 4 groups based on treatment: group 1, only artificial tears; group 2, corticosteroid eye drops and artificial tears; group 3, oral vitamin B1, mecobalamin, and artificial tears; and group 4, oral vitamin B1, mecobalamin, corticosteroid eye drops, and artificial tears. DED symptoms, signs, and patient satisfaction with treatment were assessed at baseline and at 1 and 2 months after treatment. Results. In total, 152 eyes from 76 patients (age, 55.25 ± 18.16 years) were included. In group 3, there were significant differences in dryness, foreign body sensation, burning, and tear film breakup time first (TBUTF) between 1 and 2 months after treatment and in satisfaction scores before and after treatment (P<0.05). In group 3, there were also significant differences in dryness, foreign body sensation, photophobia, and TBUTA and between baseline and 2 months after treatment (P<0.05). There was a significant difference in foreign body sensation between 1 and 2 months after treatment in groups 3 and 4 (P<0.05). Furthermore, we also find obvious improvement in corneal nerve fiber density (CNFD) between baseline and 1 and 2 months after treatment in groups 3 and 4 (P<0.05). Conclusions. Oral vitamin B1 and mecobalamin can relieve some dry eye symptoms such as dryness, pain, and photophobia and improve DED signs and patient satisfaction. Thus, vitamin B1 and mecobalamin are potential treatment options for patients with DED.

Jiarui Yang,1,* Yushi Liu,1,* Yanhui Xu,1,* Xiaodan Li,1,* Jiayu Fu,1 Xiaodan Jiang,1 Yilin Chou,1 Jiahui Ma,1 Ran Hao,1 Rong Zhang,2 Weiqiang Qiu,1 Xuemin Li11Department of Ophthalmology, Peking University Third Hospital, Beijing, People’s Republic of China; 2Department of Neurobiology, Health Science Center, School of Basic Medical Sciences, Peking University, Beijing, People’s Republic of China*These authors contributed equally to this workPurpose: To present a new ocular nebulization therapy for the treatment of dry eye disease (DED) and investigate the efficacy of vitamin B12 (VB12) and oxytocin (OXT) nebulization with clinical parameters and in vivo confocal microscopy (IVCM).Patients and methods: Thirty-eight patients with DED were enrolled, with 19 receiving VB12 nebulization and 19 receiving OXT nebulization twice weekly for 3 months. Clinical signs and symptoms including Ocular Surface Disease Index, self-assessment of light sensitivity and dryness, tear meniscus height, tear break-up time (BUT), and corneal staining, along with IVCM data of basal epithelial cell density, sub-basal dendritic cell (DC) density, nerve density, and nerve tortuosity were acquired at baseline, 1 month, and 3 months after starting treatment.Results: Patients treated with VB12 improved significantly in all signs and symptoms except for nerve tortuosity during the three-month treatment, while OXT demonstrated similar effects apart from BUT and nerve tortuosity. VB12 group revealed a higher BUT at 1 month and 3 months with a higher basal epithelial cell density at 3 months compared with OXT group, and a lower DC density was observed in OXT group at 1 month. Change of basal epithelial cell density was more significant at 3 months in VB12 group, with OXT group showing a significantly higher DC reduction at 1 month.Conclusion: The nebulization therapy delivering VB12 and OXT appears to be effective in improving the symptoms and signs of dry eye, with a relatively stronger effect of BUT elevation and epithelial repair in VB12 and anti-inflammation in OXT nebulization.Keywords: dry eye, in vivo confocal microscopy, nebulization, oxytocin, vitamin B12

This study aimed to observe corneal subbasal nerves and Langerhans cells (LCs) using in vivo confocal microscopy (IVCM) in patients with dry eye, a tool for the evaluation of disease stage and severity and for treatment monitoring at the microstructural level.A total of 107 eyes from 62 patients were included. The Ocular Surface Disease Index (OSDI) questionnaire and other examinations were used to assess dry eye symptoms and signs. IVCM was performed to observe subbasal corneal nerves and LCs. Corneal nerves were graded using both objective and subjective methods. The correlations between dry eye symptoms and corneal nerve parameters, corneal nerve grading, and LC number were analyzed.Corneal nerve length was negatively correlated with sensitivity to light [correlation coefficient (CC)= -0.24, P0.05]; nerve width was positively correlated with the OSDI score, painful eyes, and blurred vision (CC = 0.41, 0.23, and 0.46, respectively, all P0.05); and nerve tortuosity was positively correlated with sensitivity to light (CC = 0.23, P0.05). Moreover, both total objective and subjective grading scores were positively correlated with OSDI scores (CC = 0.48 and 0.27, respectively, both P0.05). LC number was found not to be significantly correlated with dry eye symptoms (P0.05).IVCM is a useful tool to evaluate corneal subbasal nerve changes in patients with dry eye. Detailed nerve grading could help to understand and evaluate the pathophysiologic conditions of the disease and could be used for further treatment follow-up in the future.

Background: Labial gland biopsies play a significant role in diagnosing primary Sjogren's syndrome (pSS) but their clinical use is limited because of their invasiveness. We assessed the value of impression cytology (IC) and in vivo confocal microscopy (IVCM) for diagnosing pSS. Methods: Consecutive patients with clinically suspected pSS (n = 102) were enrolled. According to the American College of Rheumatology-European League Against Rheumatism (ACR-EULAR) criteria, all patients underwent labial gland biopsies, serum anti-Sjogren's syndrome A (SSA)/Ro antibody testing, Schirmer's tests (STs), corneal staining and unstimulated whole saliva flow (UWS) determinations. The patients were divided into pSS (n = 28) and control (n = 74) groups, all underwent lip mucosa IC and IVCM analyses. The salivary gland ultrasonography (SGUS) score, ocular surface disease index (OSDI), tear meniscus height (TMH), tear film breakup time (BUT), and meibomian gland score were recorded. The associations between IC/IVCM parameters and clinical/laboratory results were analyzed. Findings: The absolute agreements between lip mucosal IC and the ACR-EULAR criteria (98·04%)/ labial gland biopsy (97·06%) were good. A combination of IC and anti-SSA/Ro antibody determination showed high predictive value for diagnosing pSS. Compared with controls, IVCM revealed significant lip mucosal epithelium thinning and lamina propria atrophy in the pSS group (both, P < 0·001). The sensitivities for diagnosing pSS corresponding to a lamina propria thickness ≤126 μm and a gland diameter ≤90 μm were both 85·71%; the specificities were 90·54% and 100%, respectively. A combination of IVCM results and anti-SSA/Ro antibody results showed high predictive value for diagnosing pSS. Interpretation: Characteristic cellular and morphological changes of lip mucosa in patients with pSS could be detected by IC and IVCM. These noninvasive and easy-to-perform examinations may be an alternative to labial gland biopsies for diagnosing pSS. Funding Statement: This study was supported by a grant from the Beijing Health and Family Planning Commission, Capital’s Funds for Health Improvement and Research [Grant numbers: CFH2018-2-4093]. Declaration of Interests: The authors state: "None of the authors have any conflicts of interest to report." Ethics Approval Statement: The study was performed according to the principles of the Declaration of Helsinki and was approved by the Human Research and Ethics Committee, Peking University Third Hospital; written informed consent was obtained from each study participant.

We aimed to investigate the associations among lens epithelium telomere length (LETL), cataract types, and systemic pro-senescence factors in patients with age-related cataract. In this prospective study, the general demographic factors, body mass index, smoking history, depression, hypertension, diabetes, various psychological measures, and uncorrected distant visual acuity of patients with age-related cataract were recorded. Lens Opacities Classification System III (LOCS III) scores and lens density measured by Scheimpflug imaging were used to evaluate the cataracts. LETL was measured by real-time polymerase chain reaction. Correlations among these parameters were analyzed. The LOCS III nuclear opalescence (NO) score was associated with age (β = 0.053, P 0.001) and Patient Health Questionnaire-9 score (β = -0.042, P = 0.004). Smoking was identified as a risk factor affecting LOCS III NO score (odds ratio = 1.546, 95% confidence interval, 1.128-2.119), but not the LOCS III cortical or posterior subcapsular scores. LETLs showed a weak association with systemic factors and LOCS III scores, and a significantly moderate correlation with the average objective lens densities of different regions measured by Scheimpflug imaging (r values ranged from -0.278 to -0.523, P 0.05). However, there was no correlation between the LETLs and the maximum lens densities. The groups with a relatively low lens density had longer LETLs. In Conclusion, being an age-related disease, cortical cataract was also associated with "aging of the lens epithelium." Notably, lens epithelium activity rarely showed systemic effects. Thus, future studies should emphasize the importance of the telomeric system in cataractous process and aging.

This study aimed to propose a comprehensive grading scale to evaluate different clinical manifestations in patients with varying severity of meibomian gland dysfunction (MGD) and analyze the correlations between the parameters of ocular surface impairment in MGD. A total of 63 patients with MGD were enrolled. Ten specific symptoms were evaluated each with a subjective score and total score was applied to grade the severity of MGD. Thirty-seven patients were diagnosed with mild, 19 with moderate, and 7 with severe MGD. Slit-lamp and keratography were used to assess the signs of ocular surface and meibomian gland (MG). In vivo confocal microscopy (IVCM) was performed to evaluate the corneal nerves and dendritic cells. The differences and correlations between symptoms, signs, and IVCM parameters were analyzed. Dryness, foreign body sensation, asthenopia, and photophobia were the most common and severe symptoms in our patients. The severe MGD group showed worse MG expressibility, Meibum score, Meiboscore, MG score, and higher nerve reflectivity (P