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The members of the Management and Therapy Subcommittee undertook an evidence-based review of current dry eye therapies and management options. Management options reviewed in detail included treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, surgical approaches, dietary modifications, environmental considerations and complementary therapies. Following this extensive review it became clear that many of the treatments available for the management of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due to a lack of appropriate masking, randomization or controls and in some cases due to issues with selection bias or inadequate sample size. Reflecting on all available evidence, a staged management algorithm was derived that presents a step-wise approach to implementing the various management and therapeutic options according to disease severity. While this exercise indicated that differentiating between aqueous-deficient and evaporative dry eye disease was critical in selecting the most appropriate management strategy, it also highlighted challenges, based on the limited evidence currently available, in predicting relative benefits of specific management options, in managing the two dry eye disease subtypes. Further evidence is required to support the introduction, and continued use, of many of the treatment options currently available to manage dry eye disease, as well as to inform appropriate treatment starting points and understand treatment specificity in relation to dry eye disease subtype.

Purpose To estimate the minimum number of cells required to obtain reliable data in a specular microscope, which could possibly represent the real clinical condition of the corneal endothelium. Methods A cross-sectional study of 122 eyes of 61 individuals submitted to noncontact specular microscope was conducted. Data generated by the manufacturer's software were uploaded to specific statistical software for sampling relative error calculation. When relative error was above 5%, new images were acquired and more cells counted until the desired relative error was reached. Data analyzed in this study for the desired relative error were number of cells marked by the examiner for each eye (marked cells), number of cells used for data analysis (analyzed cells), endothelial area used for analysis, sampling error, and absolute number of images used for each eye. Results The average number of marked cells required to obtain a relative sampling error of less than 5% was 425.2 ± 102.2 cells. The average number of analyzed cells used by the specular microscope to generate the data was 247.4 ± 51.6 cells. The average endothelial area of the analyzed cells was 0.43 ± 0.08 mm. The mean sampling error was 3.7% ± 0.6%, and an average of 2.95 ± 0.74 images was needed to obtain a relative sampling error of less than 5%. Conclusions We conclude that, theoretically, a minimum of 425.2 cells from 2.95 images must be marked to obtain reliable results, which could possibly represent the real endothelial clinical condition of the whole cornea.

PURPOSE To analyze 15-year of corneal transplant in Brazil. METHODS Cross-sectional, retrospective, observational, and analytical study, between available data from the Brazilian Transplant Registry (January 2002-December 2016), collected by the Brazilian Association of Organ Transplantation was performed. The variables analyzed per year were number of corneal transplants, corneal transplants per million people (pmp), corneal transplant teams, and individuals on the waiting list for corneal transplants. Quantitative variables were expressed by their respective values. To verify the relationship of time with the variables, the Spearman correlation test was applied, adopting P

Objective To describe the clinical efficacy of the treatment of Sjogren's syndrome dry eye using 0.03% tacrolimus eye drop. Design Prospective double-blind randomized study. Setting Institutional outpatient clinic. Participants Forty-eight eyes of twenty-four patients with dry eye related to Sjogren syndrome were enrolled in this study. The patients were randomized in 2 groups: tacrolimus ( n =14) and vehicle ( n =10) group. Intervention The tacrolimus group received a vial containing tacrolimus 0.03% (almond oil as vehicle) and the other group received the almond oil vehicle. All patients were instructed to use the eye drops every 12h in the lower conjunctival sac. Main outcome measures Schirmer I test, break-up-time (BUT), corneal fluorescein and Rose Bengal staining scores were evaluated in all patients one day before the treatment (baseline), 7, 14, 28 and 90 days after treatment with the eye drops. Results The average fluorescein and Rose Bengal scores improved statistically after 7 days of treatment and even more after 90 days. The average Schirmer I and BUT values were unchanged after 7, 14 and 21 days but did show an improvement relative to baseline after 28 days of treatment. Schirmer I, BUT, fluorescein and Rose Bengal did not show any statistical significance in the vehicle group. Conclusion Topical 0.03% tacrolimus eye drop improved tear stability and ocular surface status in cases of inflammatory or SS-related dry eye. Trial registration ClinicalTrials.gov Identifier: NCT01850979.

A retrospective and analytical study was conducted by using data from the National Transplantation System on 184,575 corneal transplantations performed between January 2001 and December 2016 in order to analyze thetrends in corneal transplantation from 2001 to 2016 in Brazil. The Cochran-Armitage test, analysis of variance, and Duncan’s multiple comparisons were used to verify the existence of trends, compare the mean values between regions, and verify the mean differences, respectively. A significance level of 5% was used for all tests. The analysis showed that there was a 2.4-fold increase in the number of corneal transplantations (from 6,193 [35.2 per million people (pmp)] to 14,641 [71 pmp]; p

PURPOSE: To evaluate the in vitro antimicrobial activity of aqueous humor in patients who had preoperative topical application of moxifloxacin hydrochloride 0.5%. SETTING: Department of Ophthalmology, Santa Casa de Misericde S~ Paulo, Brazil. DESIGN: Comparative case series. METHODS: Twenty-nine eyes from 29 cataract surgery patients were included in this study. In the study group (n Z 15 eyes), 3 topical applications of moxifloxacin hydrochloride 0.5% were admin- istered preoperatively; in the control group (n Z 14 eyes), no topical applications were adminis- tered. Aqueous humor samples were collected and stored in sterile microtubes at 80C until analysis. Antimicrobial analysis was performed using standard strains with standard sterile filter paper disks. Inhibition halos were measured in millimeters, and both bactericidal and bacteriostatic effects were analyzed. RESULTS: Inhibition halos were observed on most of the study group plates except those with Streptococcus pneumoniae: Escherichia coli (13.93 mm G 0.64 (SD)), Klebsiella pneumoniae (10.63 G 0.61 mm), Staphylococcus aureus (7.47 G 0.68 mm), and S epidermidis (4.20 G 3.33 mm) The differences between the mean inhibition halo diameters were statistically significant (P < .0001) in all samples. No bactericidal effect was observed against any of the micro- organisms studied. CONCLUSIONS: After topical application of moxifloxacin 0.5%, aqueous humor showed bacterio- static effect against E coli, K pneumoniae, S aureus, and S epidermidis. No bactericidal effect was observed against any of the microorganisms evaluated. No antimicrobial effect against S pneu- moniae was observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

This prospective, randomized, double-blind interventional case series was designed to evaluate the short-term efficacy of 0.03% tacrolimus ointment as a new therapeutic approach for refractory cases of posterior blepharitis.Forty eyes (20 patients) with posterior blepharitis refractory to previous treatment were randomized. Eighteen eyes (9 patients) were treated with 0.03% tacrolimus ointment and 20 eyes (10 patients) with placebo ointment twice daily. Patients were evaluated with a questionnaire and slit-lamp examination 14 days and 28 days after treatment, and symptoms and signs of blepharitis were compared to those observed at baseline.We could observe statistical difference in the outcome measurements of meibomian gland secretion, conjunctival hyperemia, telangiectasia of inferior lid, Rose Bengal, and fluorescein scoring for the study group. As for the symptoms score, we observed statistical difference in the symptoms scoring for pruritus and dry eye sensation in the tacrolimus group.This study suggests that topical administration of 0.03% tacrolimus ointment can improve some symptoms and some ocular surface status in patients with refractory posterior blepharitis.

The aim of this study was to identify inequalities in corneal donation and transplantation among the regions of Brazil. A transversal and retrospective study was specifically conducted using data from the Brazilian Transplant Registry collected by the Brazilian Association of Organ Transplantation between January 2002 and December 2014. The collected data were processed using descriptive statistical methods, and p

To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye related to Sjögren syndrome.Thirty-seven eyes of 19 patients (3 male and 16 female; 49.11 ± 14.33 years old) with keratoconjunctivitis sicca were enrolled in this study. Superior and inferior partial occlusion were performed in both eyes under topical anesthesia using thermal cautery with a sterile tip to obtain lacrimal punctum smaller than 0.5 mm. Schirmer I, break-up-time, diameter of lacrimal puncta, corneal fluorescein, and rose Bengal staining scores were analyzed before and after 24 weeks and after 24 months of the procedure. All measurements were performed under controlled climate.The average lacrimal punctum diameter before the procedure was 0.65 ± 0.134 mm. All lacrimal puncta were successfully reduced to less than 0.5 mm after 4 weeks of the procedure. The average Schirmer I test values improved statistically after 24 weeks and maintained stable after 24 months. Average break-up-time, rose Bengal, and fluorescein staining score values improved statistically after 24 weeks and improved even more after 24 months. Average Schirmer I test, break-up-time, rose Bengal, and fluorescein staining scores showed significant improvement (p 0.0001) after 24 months of partial thermal punctal occlusion.Our study showed that reducing the punctum diameter to 0.5 mm can improve vital staining scores, break-up-time, and Schirmer I test in dry eye related to Sjögren syndrome.

Purpose To detect the inflow of trypan blue through grooved and nongrooved sutureless self-sealing clear corneal incisions at the end of phacoemulsification as compared to a control group. Methods A prospective randomized masked trial considered 52 eyes randomized into 3 groups in which phacoemulsification was performed: group A, nongrooved incisions; group B, grooved incisions; and group C, controls. By the end of each surgery, trypan blue was instilled on the ocular surface in groups A and B and rinsed out after 2 minutes. A sample of the anterior chamber content was collected and analyzed by high-performance liquid chromatography to identify and quantify the trypan blue concentration. The presence of trypan blue was expressed as a specific single peak graphic image. The mean areas of these peaks were used to assess the groups using a nonparametric Mann-Whitney test. Results There was a statistically significant difference between the nongrooved incisions group and the control group (p = 0.0448). No significant difference was observed between group B (grooved incision) and controls (p = 0.1800). Conclusions Trypan blue was detected in the anterior chamber when nongrooved clear corneal incision was used. There was no trypan blue detection in the group with grooved clear corneal main incisions.

To analyze levels of alpha -defensin in the tears of allergic patients (with/without corneal lesions) comparing the results with those of normal control subjects.Screening of the protein profiles of the tears of allergic patients with corneal epithelial lesions and normal controls was performed by surface enhanced laser desorption/ionization (SELDI) ProteinChip array initially. ELISA was then performed to quantify the levels of alpha -defensin in the tears of allergic patients (with/without corneal epithelial lesions) and normal control patients.Proteins expressing significant differences between patients and controls by SELDI analysis were examined. Several peptides with molecular weights similar to alpha -defensins were found to be expressed to a greater extent in allergic patients. ELISA was performed in tears of allergic patients and control subjects to ascertain the presence and increased expression of alpha -defensins in allergic patients. Concentrations of alpha -defensins in allergic patients with corneal epithelial lesions were significantly higher than those of allergic patients without epithelial lesions or normal controls.Alpha-defensins were found in greater concentrations in tears of allergic patients with corneal lesions. The antimicrobial effects of alpha -defensins may play a role in the prevention of secondary infection of corneal lesions in allergic patients. SELDI ProteinChip technology is a useful and effective tool in profiling the differential expression of proteins in tears.

To report the clinical outcome of the treatment of dry eyes using 0.03% tacrolimus eye drops (olive oil + tacrolimus 0.03%) (Ophthalmos, Sao Paulo, Brazil).Sixteen eyes of 8 patients with Sjögren syndrome dry eyes (age, 51.13 ± 9.45 years) were enrolled in this study (prospective noncontrolled interventional case series). Patients were instructed to use topical 0.03% tacrolimus eye drops twice a day (every 12 hours) in the lower conjunctival sac. Schirmer I test, break-up time, corneal fluorescein, and rose bengal staining score were performed in all patients 1 day before, and 14, 28, and 90 days after treatment with 0.03% tacrolimus eye drops.The average fluorescein staining and rose bengal staining scores improved statistically significantly after 14 days of treatment and improved even more after 28 and 90 days. The average Schirmer I test did not improve statistically significantly after 28 days of treatment, although we did observe a significant improvement after 90 days of treatment with 0.03% tacrolimus eye drops. The average break-up time did not improve statistically after 14 days of treatment, although we observed a significant improvement after 28 and 90 days of treatment with 0.03% tacrolimus eye drops.Topical 0.03% tacrolimus eye drops successfully improved tear stability and ocular surface status in patients with dry eyes.

Purpose: To analyse the ocular surface changes in eyes with functioning filtering blebs and to correlate with the size of the bleb.Materials and methods: Forty eyes of 40 glaucomatous patients with functioning blebs and 40 normal control subjects underwent double vital staining for ocular surface evaluation, tear film break-up-time (BUT) and Schirmer I-test in a standardized fashion. Mann–Whitney U-test and Spearman’s rank correlation were used to correlate bleb height and horizontal extent with BUT, Schirmer I-test, rose bengal and fluorescein staining scores.Results: Eyes with functioning blebs presented minimal, but significantly, higher rose bengal and fluorescein staining than controls (p

To evaluate the effects of oral azithromycin in patients with posterior blepharitis.Twenty-six eyes of 13 patients with posterior blepharitis diagnosed by a qualified ophthalmologist were enrolled in this study. Patients were instructed to use oral azithromycin 500 mg per day for 3 days in 3 cycles with 7-day intervals. Subjective clinical outcomes were graded and scored 1 day before and 30 days after the end of the treatment (53 days after initiating the treatment) based on severity scores of: (1) eyelid debris; (2) eyelid telangiectasia; (3) swelling of the eyelid margin; (4) redness of the eyelid margin; and (5) ocular mucus secretion. For the assessment of global efficacy, patients were asked by the investigator to rate the subjective symptoms (eyelid itching, ocular itching, eyelid hyperemia, ocular hyperemia, ocular mucus secretion, photophobia, foreign body sensation, and dry eye sensation) on a scale of 0 (no symptoms) to 5 (severe symptoms). Break-up time, Schirmer I test, corneal fluorescein staining score, and rose bengal staining score were also performed in all patients.All clinical outcomes scoring showed statistically significant improvement after oral azithromycin, except for eyelid swelling. Average subjective symptom grading improved statistically after treatment with oral azithromycin, except for eyelid hyperemia, photophobia, and foreign body sensation. Average tear film break-up time values showed statistically significant improvement after the treatment with oral azithromycin. No statistically significant improvement was observed on average values of Schirmer I test, corneal fluorescein staining score, and rose bengal staining score.The combination of multiple clinical parameters shown in this study supports the clinical efficacy of pulsed oral azithromycin therapy for the management of posterior blepharitis.

OBJETIVO: Analisar a diferenca das medidas dos testes de Schirmer I e Schirmer basal realizados com os olhos abertos e olhos fechados. METODOS: Foram analisados 60 olhos de 30 individuos normais com idade media de 28 ± 9 anos. A umidade media do ar foi de 60 ± 2,34% e a temperatura media de 20,72 ± 1,52oC. No primeiro dia, foi feito o teste de Schirmer I com os olhos abertos. Apos um intervalo de 6 horas, foi realizado o teste de Schirmer I com os olhos fechados. No segundo dia, foi realizado o mesmo procedimento com o teste de Schirmer basal. Para fins de comparacao, as medidas das tiras de papel foram divididas pelo tempo de umedecimento das tiras (velocidade) para analise estatistica. RESULTADOS:No teste de Schirmer I realizado com os olhos abertos, a medida de umedecimento das tiras mostrou ser estatisticamente maior quando comparado com a medida do mesmo teste realizado com olhos fechados (p

Eotaxin, a CC-chemokine with selective chemotactic effects for eosinophils, has been reported to play an important role in allergic conjunctival diseases. We previously reported that eotaxin is produced by conjunctival fibroblasts and keratocytes on stimulation with Th2 cytokines. Tranilast is known to have anti-allergic properties. In this study, we examined the inhibitory effect of tranilast, an anti-allergic drug, on eotaxin-1 production from cultured conjunctival fibroblasts.Conjunctival fibroblasts obtained from normal patients were cultured in DMEM/F12 medium. On the fifth passage, the cells were transferred to a 96-well plate and, after starvation for 24 hr, TNF-alpha, IL-4, and tranilast or dexamethasone were added. After 48 hr, the concentrations of eotaxin-1 in the supernatants were measured by ELISA, and the cells were tested for eotaxin-1 expression by real-time PCR.Eotaxin-1 production was observed on simultaneous stimulation with TNF-alpha and IL-4. This production was inhibited by both tranilast and dexamethasone. Inhibition of eotaxin-1 expression was also observed by real-time PCR.Eotaxin-1 production from conjunctival fibroblasts was inhibited by both tranilast and dexamethasone. These results suggest that the anti-allergic effect of tranilast may be partly due to the inhibition of eotaxin-1 production from conjunctival fibroblasts.

Purpose To analyze the antimicrobial properties of ethyl-cyanoacrylate (Superbonder, Loctite, Brazil) in vitro in different microorganisms related to corneal infections. Methods We analyzed the following microorganisms: (1) Staphylococcus aureus (multiresistant); (2) S. aureus (ATCC 25923); (3) coagulase-negative Staphylococcus; (4) Streptococcus pyogenes; (5) Streptococcus pneumoniae; (6) Pseudomonas aeruginosa (multiresistant); (7) P. aeruginosa (ATCC 27853); (8) Escherichia coli (ATCC25922); and (9) Enterococcus faecalis (ATCC 29212). One drop of the glue was dropped directly into the nutrient broth. The plates were incubated at 35 +/- 2 degrees C and its growth examined after 24 hours. Bactericidal activity of the glue was verified by sampling inhibition zones when present. The samples were plated in blood agar an analyzed after 24 and 48 hours. Results The ethyl-cyanoacrylate inhibited the growth of every gram-positive microorganism tested and showed bactericidal effect over 70% for all of them. Among the gram-negative microorganisms, only the E. coli and the E. faecalis had its growth inhibited, and the bactericidal effect was 60% and 40%, respectively. Conclusion The ethyl-cyanoacrylate has bacteriostatic and bactericidal action in vitro, mainly against gram-positive microorganisms.