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Abstract Introduction Despite an improved understanding of its pathogenesis, dry eye disease (DED) remains relatively underestimated and its treatment challenging. A better alignment between the clinical evaluation and the patient self-assessment also requires capturing the whole patient experience of DED. This project aimed to unveil this experience through narrative medicine (NM). Methods The project involved 38 expert centres in Italy and one in San Marino, targeting adult patients with DED, their informal caregivers and their treating ophthalmologists. Written narratives and sociodemographic and quality of life (QoL)-related data were anonymously collected through the project’s webpage. Narratives were analysed through MAXQDA (VERBI Software, Berlin, Germany), NM classifications and content analysis. Results A total of 171 patients with DED, 37 informal caregivers and 81 ophthalmologists participated in the research. DED was defined as a disabling condition by 19% of patients and 35% of caregivers; 70% of patients reported that a therapeutic alliance is an integral part of DED treatment and 32% hope for more effective therapies. Forty-four per cent of patients assessed their own QoL as good; however, DED emerged as importantly impacting work performance and social events. DED physical, emotional and economic burden and the cruciality of a trusting care relationship represent the main themes that emerged across all narratives, while empathy and effective treatment are among the factors favouring coping with DED. Conclusion This project marked a pioneering initiative investigating the lived experience of patients with DED through NM, simultaneously involving all viewpoints involved in the care pathway. NM enabled the unveiling of factors favouring the ability to cope with DED and its associated QoL implications and provided valuable insights to improve the therapeutic alliance.

Lactoferrin (Lf), a multifunctional protein found abundantly in secretions, including tears, plays a crucial role in ocular health through its antimicrobial, immunoregulatory, anti-inflammatory, and antioxidant activities. Advanced delivery systems are desirable to fully leverage its therapeutic potential in treating ocular diseases. The process of Lf quantification for diagnostic purposes underscores the importance of developing reliable, cost-effective detection methods, ranging from conventional techniques to advanced nano-based sensors. Despite the ease and non-invasiveness of topical administration for ocular surface diseases, challenges such as rapid drug elimination necessitate innovations, such as Lf-loaded contact lenses and biodegradable polymeric nanocapsules, to enhance drug stability and bioavailability. Furthermore, overcoming ocular barriers for the treatment of posterior segment disease calls for nano-formulations. The scope of this review is to underline the advancements in nanotechnology-based Lf delivery methods, emphasizing the pivotal role of multidisciplinary approaches and cross-field strategies in improving ocular drug delivery and achieving better therapeutic outcomes for a wide spectrum of eye conditions.

Pupillometry is a promising technique for the potential diagnosis of several neurological pathologies. However, its potential is not fully explored yet, especially for prediction purposes and results interpretation. In this work, we analyzed 100 pupillometric curves obtained by 12 subjects, applying both advanced signal processing techniques and physics methods to extract typically collected features and newly proposed ones. We used machine learning techniques for the classification of Optic Neuritis (ON) vs. Healthy subjects, controlling for overfitting and ranking the features by random permutation, following their importance in prediction. All the extracted features, except one, turned out to have significant importance for prediction, with an average accuracy of 76%, showing the complexity of the processes involved in the pupillary light response. Furthermore, we provided a possible neurological interpretation of this new set of pupillometry features in relation to ON vs. Healthy classification.

Oxidative stress and inflammation determine retinal ganglion cell degeneration, leading to retinal impairment and vision loss. Müller glial cells regulate retinal repair under injury, through gliosis. Meanwhile, reactive gliosis can turn in pathological effects, contributing to neurodegeneration. In the present study, we tested whether Cord Blood Serum (CBS), rich of growth factors, might improve the viability of Müller cells under in vitro damage. BDNF, NGF, TGF-α, GDNF and EGF levels were measured in CBS samples by Human Magnetic Luminex Assay. CBS effects were evaluated on rat (rMC-1) and human (MIO-M1) Müller cells, under H2O2 and IL-1β damage. Cells grown with FBS or CBS both at 5% were exposed to stress and analyzed in terms of cell viability, GFAP, IL-6 and TNF-α expression. CBS was also administrated after treatment with K252a, inhibitor of the neurotrophin receptor Trk. Cell viability of rMC-1 and MIO-M1 resulted significantly improved when pretreated with CBS and exposed to H2O2 and IL-1β, in comparison to the standard culture with FBS. Accordingly, the gliosis marker GFAP resulted down-regulated following CBS priming. In parallel, we observed a lower expression of the inflammatory mediators in rMC-1 (TNF-α) and MIO-M1 (IL-6, TNF- α), especially in presence of inflammatory damage. Trk inhibition through K252a administration impaired the effects of CBS under stress conditions on MIO-M1 and rMC-1 viability, not significantly different from FBS condition. CBS is enriched with neurotrophins and its administration to rMC-1 and MIO-M1 attenuates the cytotoxic effects of H2O2 and IL-1β. Moreover, the decrease of the main markers of gliosis and inflammation suggests a promising use of CBS for neuroprotection aims. This study is a preliminary basis that prompts future investigations to deeply explore and confirm the CBS potential.

Chiara Fariselli, Giuseppe Giannaccare, Michela Fresina, Piera Versura Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine, School of Medicine (DIMES), Alma Mater Studiorum University of Bologna and St Orsola-Malpighi Teaching Hospital, Bologna, Italy Aim: To assess the ocular surface parameters, inflammatory marker level in tears, and mucin expression in conjunctival epithelium before and after treatment with trehalose/hyaluronate tear substitute in dry eye (DE) patients.Patients and methods: Fifteen DE patients were evaluated in an open-label, pilot study at enrollment, after 2 days of washout (baseline) and after 1 and 2 months (endpoint) of treatment with a trehalose/hyaluronate tear substitute (one drop/eye/three times daily). Data for symptoms of discomfort (Ocular Surface Disease Index and Visual Analogue Scale pain score), tear film (Schirmer test I, tear film breakup time), ocular surface damage (corneal National Eye Institute) and conjunctival van Bijsterveld scores, impression cytology scored by Nelson’s grade and goblet cells (GCs) number/mm2 analysis, and MUC4 immunostaining, and inflammation (interleukin [IL]-1β, IL-6, and IL-8 levels) were measured.Results: Significant changes at endpoint as compared to baseline were found for Ocular Surface Disease Index score (respectively, mean±SD, 22.2±2.9 vs 38.7±12.7), Visual Analogue Scale score (3.4±1.3 vs 6.6±1.4), tear film breakup time (8.6±1.28 vs 6.17±1.9 seconds), corneal staining (National Eye Institute grade 1.23±0.64 vs 3.37±0.49), conjunctival staining (1.73±1.14 vs 4.17±0.91), impression cytology (Nelson grade 1.10±0.20 vs 1.63±0.54), and GC density (139.9±22.0 vs 107.8±16.2 GC/mm2). IL-1β, IL-6, and IL-8 tear levels showed a significant decrease at endpoint as compared to baseline (respectively, pg/mL tears: 12.3±6.9, 26.6±25.2, 743.5±477.7 vs 33.6±17.3, 112.0±24.3, 1,139.2±671.7).Conclusions: A decrease in ocular discomfort symptoms, surface damage, and tear cytokine levels was shown after 2 months’ treatment with trehalose/hyaluronate tear substitute in DE patients, along with a significant GC density recovery. These results may be associated with the synergic action of both trehalose and hyaluronic acid in targeting different entries of the DE vicious loop. Keywords: dry eye, trehalose, hyaluronic acid, tear substitute, inflammation

Piera Versura, Giuseppe Giannaccare, Marco Pellegrini, Stefano Sebastiani, Emilio C Campos Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Sant’Orsola-Malpighi Teaching Hospital, Bologna, Italy Abstract: Neurotrophic keratitis (NK) is a degenerative corneal disease caused by damage of trigeminal corneal innervation, which leads to spontaneous epithelial breakdown and corneal ulceration. The impairment of corneal sensory innervation causes the reduction of both protective reflexes and trophic neuromodulators that are essential for the vitality, metabolism, and wound healing of ocular surface tissues. A wide range of ocular and systemic conditions, including herpetic keratitis, ocular chemical burns, corneal surgery, diabetes, multiple sclerosis, and neurosurgical procedures, can cause NK by damaging trigeminal innervation. Diagnosis of NK requires careful investigation of any ocular and systemic condition associated with the disease, complete ocular surface examination, and quantitative measurement of corneal sensitivity. The clinical stages of NK range from corneal epithelial alterations (stage 1) to persistent epithelial defect (stage 2) and ulcer (stage 3), which may progress to corneal perforation. Management of NK is based on clinical severity, and the aim of the therapy is to halt the progression of corneal damage and promote epithelial healing. Although several medical and surgical treatments have been proposed, no therapies are currently available to restore corneal sensitivity, and thus, NK remains difficult and challenging to treat. The purpose of this review is to summarize available evidence on the pathogenesis, diagnosis, and treatment of NK. Novel medical and surgical therapies including the topical administration of nerve growth factor and corneal neurotization are also described. Keywords: neurotrophic keratitis, neurotrophic corneal ulcer, corneal nerves

Ocular graft-versus-host disease (oGVHD) is a manifestation of chronic GVHD, frequently occurring in patients after allogeneic hematopoietic stem cell transplant (HSCT). We analyzed tear protein changes before and after allogeneic HSCT, and correlated their levels with the oGVHD development. This retrospective study included 102 patients, and data were recorded before the conditioning treatment, and after 3 to 6 months postoperatively. Tear protein analysis was performed with the Agilent-2100 Bioanalyzer on individual tears sampled by aspiration. Total protein (TP), Lysozyme-C (LYS-C), Lactoferrin (LACTO), Lipocalin-1 (LIPOC-1), Transferrin (TRANSF), Albumin (ALB), and Zinc-alpha-2-glycoprotein (ZAG-2) levels were retrieved and statistically analyzed. Following HSCT forty-three patients developed oGVHD. TP, LACTO, LYS-C, and ZAG-2 levels significantly decreased post-HSCT as compared to pre HSCT levels. In univariate analysis, TP, LACTO, and ZAG-2 decrease was associated with an increased development of oGVHD (OR = 4.49; 95% CI, 1.9 to 10.5; p < 0.001; OR = 3.08; 95% CI 1.3 to 7.6; p = 0.01; OR = 11.1; 95% CI 2.7 to 46.6; p < 0.001, respectively). TRANSF post-HSCT levels significantly increased (OR 15.7; 95% CI, 4.1 to 52.2; p = 0.0001). No pre-post-HSCT changes were shown in ALB and LIPOC-1 levels. Data suggest that TP content, LACTO, TRANSF, and ZAG-2 pre-post changes might be significant predictors of oGVHD development.

Purpose: Many semi-automated and fully-automated approaches have been proposed in literature to improve the objectivity of the estimation of conjunctival hyperemia, based on image processing analysis of eyes’ photographs. The purpose is to improve its evaluation using faster fully-automated systems and independent by the human subjectivity. Methods: In this work, we introduce a fully-automated analysis of the redness grading scales able to completely automatize the clinical procedure, starting from the acquired image to the redness estimation. In particular, we introduce a neural network model for the conjunctival segmentation followed by an image processing pipeline for the vessels network segmentation. From these steps, we extract some features already known in literature and whose correlation with the conjunctival redness has already been proved. Lastly, we implemented a predictive model for the conjunctival hyperemia using these features. Results: In this work, we used a dataset of images acquired during clinical practice.We trained a neural network model for the conjunctival segmentation, obtaining an average accuracy of 0.94 and a corresponding IoU score of 0.88 on a test set of images. The set of features extracted on these ROIs is able to correctly predict the Efron scale values with a Spearman’s correlation coefficient of 0.701 on a set of not previously used samples. Conclusions: The robustness of our pipeline confirms its possible usage in a clinical practice as a viable decision support system for the ophthalmologists.

Giuseppe Giannaccare, Michela Fresina, Alberto Pazzaglia, Piera Versura Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Sant’Orsola‑Malpighi Teaching Hospital, Bologna, Italy Abstract: Graft rejection is the most significant complication corneal transplantation and the leading indication for overall corneal transplantation. Corticosteroid therapy represents the mainstay of graft rejection treatment; however, the optimal route of administration of corticosteroid remains uncertain. We report herein for the first time the multimodal imaging of a case of long-lasting corneal endothelial graft rejection successfully reversed 3 months after dexamethasone intravitreal implant. A 29-year-old Asian female presented with a long-lasting corneal endothelial graft rejection in her left phakic eye. She underwent penetrating keratoplasty for advanced keratoconus 24 months before presentation. Hourly dexamethasone eyedrops, daily intravenous methylprednisolone, and one parabulbar injection of methylprednisolone acetate were administered during the 5 days of hospitalization. However, the clinical picture remained approximately unchanged despite therapy. By mutual agreement, we opted for the off-label injection of dexamethasone 0.7 mg intravitreal implant in order to provide therapeutic concentrations of steroid for a period of ~6 months. No other concomitant therapies were prescribed to the patient. Visual acuity measurement, slit lamp biomicroscopy, anterior segment photography, confocal microscopy, anterior segment optical coherence tomography, laser cell flare meter, intraocular pressure measurement, and ophthalmoscopy were performed monthly for the first postoperative 6 months. Three months after injection, both clinical and subclinical signs of rejection disappeared with a full recovery of visual acuity to 20/30 as before the episode. Currently, at the 12-month follow-up visit, the clinical picture remains stable without any sign of rejection, recurrence, or graft failure. Dexamethasone intravitreal implant seems to be a new potential effective treatment for corneal graft rejection, particularly in case of poor compliance or lack of response to conventional treatment. In addition, it could be especially useful in diabetic patients unable to receive systemic steroids. Keywords: keratoplasty, corneal graft rejection, dexamethasone intravitreal implant, confocal microscopy, keratoconus

Age-related macular degeneration (AMD) is one of the leading causes of visual loss in western countries, it has no cure, and its incidence will grow in the future, for the overall population aging. Albino rats with retinal degeneration induced by exposure to high-intensity light (light-damage, LD) have been extensively used as a model of AMD to test neuroprotective agents. Among them, trophic factors (NGF and BDNF) have been shown to play a significant role in photoreceptors’ survival. Interestingly, cord blood serum (CBS) is an extract full of chemokines and trophic factors; we, therefore, hypothesized that CBS could be an excellent candidate for neuroprotection. Here, we investigate whether CBS-based eye drops might mitigate the effects of light-induced retinal degeneration in albino rats. CBS treatment significantly preserved flash-electroretinogram (f-ERG) response after LD and reduced the “hot-spot” extension. Besides, CBS-treated animals better preserved the morphology of the outer nuclear layer, together with a reduction in microglia migration and activation. Interestingly, the treatment did not modulate reactive gliosis and activation of the self-protective mechanism (FGF2). In conclusion, our results suggest that CBS-based eye drops might be successfully used to mitigate retinal neurodegenerative processes such as AMD.

Purpose. To report data which happened to be observed in two glaucoma patients treated with Cord Blood Serum (CBS) eye drops. Design. A case report and retrospective data analysis. Methods. CBS topical eye drops, characterized in advance for growth factors (GFs) content, were administered for two months with the aim to relieve their subjective symptoms, in two patients who had referred ocular surface discomfort, although in absence of any sign of keratopathy. As patients were also affected by advanced glaucoma at risk of vision loss and under treatment with hypotensive drugs, they had been also monitored over the same period with IOP controls and visual field tests in our unit. Results. During subsequent visits, data from Mean Deviation and Pattern Standard Deviation in the visual fields were retrospectively collected and compared with before and after treatment with CBS, and an amelioration was observed. Conclusions. CBS contains a combination of GFs, which potentially exert a neuroprotective action and elect CBS as an interesting natural source to be delivered in neurodegenerative ocular disorders. The incidentally observed amelioration in these two patients deserves further investigation in this respect.

Giuseppe Giannaccare,1 Michela Fresina,1 Aldo Vagge,2 Piera Versura1 1Ophthalmology Unit, DIMES, S Orsola-Malpighi Teaching Hospital, University of Bologna, Bologna, Italy; 2Eye Clinic, DiNOGMI, University of Genoa, Genoa, Italy Abstract: This report describes a case of a 72-year-old Caucasian woman presenting with a large neurotrophic keratitis with a large persistent epithelial defect, with a longest linear diameter of 7 mm and greatest perpendicular width of 5 mm, affecting epithelium, Bowman membrane, and anterior stroma. Corneal disease was resistant to conventional treatment and classified as stage 2 according to Mackie classification. Patient was instructed to instill regenerating agent (RGTA) eye drops in the morning, as the first eye drop, once every 5 days in combination with daily cord blood serum (CBS) eye drops 6 times/day. The patient was asked to visit after 1 week (V1), 2 weeks (V2), 3 weeks (V3), and 4 weeks (V4) of study treatment. In V4 treatment, corneal sensitivity improved, and keratitis healed with resolution of stromal inflammation. Global treatment tolerance was very satisfactory. Patient continued the therapy for a further month after complete healing. Currently, the patient has been followed up for 3 months without any sign of keratitis recurrence. To the best of our knowledge, this case report describes for the first time the successful combined use of RGTA and CBS eye drops for the treatment of neurotrophic keratitis resistant to conventional treatment. We hypothesize that RGTA eye drops could provide an optimal migration substrate and that growth factors supplied by CBS eye drops could strengthen the repair process by promoting cell growth over the matrix. Combined RGTA and CBS eye drop therapy could be a new potential option for the successful treatment of resistant neurotrophic keratitis, particularly when each drug alone is not effective. Keywords: neurotrophic keratitis, regenerating agent, cord blood serum eye drops, penetrating keratoplasty, in vivo confocal microscopy

Objective. The international criteria for primary Sjögren’s Syndrome (SS I) diagnosis (Vitali et al. 2002) include the Schirmer test I and vital dye staining as tests for ocular surface involvement, but diagnosis can be reached also when the item for ocular signs is not satisfied. The purpose of our study was to evaluate the ocular surface in patients with Sjögren’s Syndrome, non- Sjögren’s autoimmune diseases and Sicca Syndrome, to understand whether the SS I diagnosis can be targeted also on other tests related to the ocular surface status. Methods. Clinical and cytological data were collected from 122 patients: 40 patients had diagnosis of Primary Sjögren’s Syndrome, 51 a non Sjögren’s autoimmune disease and 31 had symptoms of dry eye. A validated questionnaire on symptoms was filled by each patient; clinical tests included: Schirmer test I, Jones test, Ferning test, Break Up Time, corneal aesthesiometry, tear clearance test, vital dye staining of the ocular surface, scraping and impression conjunctival cytology. Data were statistically evaluated by using SPSS software and Mann-Whitney analysis on unpaired data. Results. Data show that the subjective symptoms score, tear production, tear turnover, corneal sensitivity and ocular surface integrity are affected in SS I patients, with a statistically significant difference when matched to the other two groups. Conclusions. Our results suggest to enlarge the spectrum of ocular surface analysis, to support and orient a differential diagnosis among the autoimmune diseases.

Piera Versura, Vincenzo Profazio, Nicole Balducci, Emilio C CamposOphthalmology Unit, Alma Mater Studiorum University of Bologna, Bologna, ItalyPurpose: To evaluate the efficacy and tolerability of Xiloial® monodose eyedrops in the treatment of patients suffering from subjective symptoms of discomfort related to disposable soft contact lens (dSCL) wear.Methods: Fifteen (12 female, three male, medium age 39 ± 9 years) dSCL wearers were enrolled. Inclusion criteria were Ocular Surface Disease Index (ODSI) symptom questionnaire score >12, tear film break-up time (TFBUT) 10 mm over five minutes, mild punctuate keratopathy, and conjunctival staining (Oxford grading ≤4). Monodose Xiloial eyedrops were administered three times daily for a two-month period. Patients were evaluated at enrollment, after three days of washout (baseline), and after one and two months of treatment, by OSDI score, Schirmer test I, TFBUT, ferning test, ocular surface damage (Oxford grade), and serum albumin in tears (index of passive exudation related to serum leakage).Results: At endpoint versus baseline, respectively, the mean ± standard deviation of all variables improved as follows: OSDI (8.5 ± 3 versus 20.2 ± 1.6); TFBUT (9.6 ± 1.1 versus 7.1 ± 1.0); Oxford grading (0.5 ± 0.1 versus 3.6 ± 0.8); ferning test (2 ± 1 versus 2.4 ± 0.5); and Schirmer test I (14.6 ± 1.1 versus 12 ± 2.1), with P < 0.05 for all variables (Friedman and Wilcoxon tests). Tolerability was high, with no adverse events noted.Conclusions: A two-month treatment with Xiloial showed good tolerance and appeared to reduce ocular surface damage and symptoms of discomfort.Keywords: discomfort, dry eye, disposable contact lens, biopolymer tamarind seed polysaccharide–hyaluronic acid

Piera Versura, Vincenzo Profazio, Emilio C CamposDepartment of Surgery and Anesthesiology, Section of Ophthalmology, Alma Mater Studiorum University at Bologna, Bologna, ItalyThe data in this paper were first presented at the 9th International Ocular Inflammation Society (IOIS) Annual Meeting, September 17–20, 2007, Paris, France, and the European Association for Vision and Eye Research (EVER) Congress, October 3–6, 2007, Portoroz, SloveniaObjective: To evaluate the efficacy of Systane® Lubricating Eye Drops in improving the symptoms of moderate ocular dryness.Methods: Fifty subjects with moderate symptoms of ocular dryness were enrolled in this open label study. The mean age of subjects was 57.6 ± 15.4 years. To be eligible, subjects’ tear film break-up time (TFBUT) had to be

Introduction: Dry eye disease is a multifactorial disease which affects the ocular surface system, and determines ocular discomfort symptoms and visual disturbance. Various types of ocular surgery, including strabismus one, represents a recognized cause for iatrogenic dry eye. However, it is not uncommon that strabismus patients, even not undergone to surgery, report symptoms of ocular discomfort and dryness. Hypothesis We hypothesize that two possible mechanisms may determine dry eye in strabismus patients by setting up a specific vicious circle: firstly, the increased exposure of the area of the bulbar conjunctiva located on the opposite side compared to the deviation may cause the thinning of the tear film lipid layer, with increased tear film instability; secondly, the dysfunctional lubricity secondary to the altered relationship between the eyelids and the deviated globe may cause blinking-related microtrauma, and thus inflammation and tear hyperosmolarity. These two entry points into the vicious circle of dry eye may determine a cascade of detrimental mechanisms, leading to further damage of the tear film, thus closing the disease circle.Discussion: Strabismus patients may be affected by signs and symptoms of dry eye syndrome. The increased exposure of the bulbar conjunctival area along with the dysfunctional lubricity between the eyelids and the deviated eye could be the main underlying pathophysiological mechanisms acting as entry points into the vicious circle of dry eye disease. If our hypothesis was to be confirmed, ocular surface parameters should be routinely investigated in strabismus patients, whilethe use of tear substitutes with the aim of moistening and nourishing the ocular surface could help in reducing dry eye signs and symptoms. [ABSTRACT FROM AUTHOR]