Contact lens-related dry eye

Systane Ultra Lubricant Eye Drops for Treatment of Contact Lens-Related Dryness

McDonald M, Schachet JL, Lievens CW, Kern JR. Eye & Contact Lens 2014;40:106-110

This randomized, investigator-masked study looked at 89 daily disposable contact lens wearers who experience contact lens-related dryness. 44 were assigned to the Systane Ultra treatment group and 45 to the untreated control group. For two weeks the treatment group applied Systane Ultra lubricant 10 minutes before lens insertion and after lens removal. Subjective comfort, wear time, and visual acuity were assessed at baseline and after two weeks.

Results showed two weeks of treatment with Systane Ultra lubricant eye drops resulted in a significant increase in comfortable lens wear time when compared with baseline assessment (P=0.001) and a trend toward significant improvement compared with the control group (P=0.078). End of day comfort was significantly improved in the treatment group compared to the control group (P=0.007). A significant reduction in overall dryness (P<0.001) and end of day dryness (P=0.047) was observed in the treatment group compared to the control group.

The authors conclude that the study demonstrates that Systane Ultra lubricant eye drops applied before and after contact lens wear is an effective artificial tear for alleviating symptoms of contact lens-related dry eye.

My comment:

Dry eye is a common problem among contact lens wearers, and improved lubrication certainly improves lens wearer comfort and lowers the risk of ocular surface complications from contact lens wear. This study was supported by Alcon BUT the use of Systane Ultra drops as prescribed resulted in an extra 1.44 hours of comfortable lens wear time compared to no treatment. That is significant and the regime was very simple.

Preservative-free steroid drops

Comparison of Efficacy and Ocular Surface Toxicity of Topical Preservative-free Methylprednisolone and Preserved Prednisolone in the Treatment of Acute Anterior Uveitis

Hedayatfar A, Hashemi H, Asgari S, Chee SP. Cornea 2014; 33:366-372

This prospective, randomised, investigator-masked, comparative clinical trial compared the anti-inflammatory effect and ocular surface toxicity of topical nonpreserved methylprednisone sodium succinate 1% and preserved prednisolone acetate suspension 1% for the management of acute anterior uveitis (AAU). Group A (n=38) received hourly nonpreserved methylprednisolone 1% and group B (n=34) received hourly preserved prednisolone 1% eye drops, both groups followed a two-week tapering regimen. Anterior chamber (AC) cells and flare were clinically evaluated for objective comparison of the anti-inflammatory effect. The main outcome measure was the percentage of patients with a resolution of inflammation (AC cells <1+) on day 14. Ocular surface toxicity was assessed by corneal fluorescein staining score, tear breakup time, Schirmer I test, and questionnaire-based grading of ocular discomfort parameters.

Results showed that on day 14, 76.3% of group A patients compared with 70.6% of group B patients had resolution of inflammation, proving noninferiority (c2 = 0.303, P=0.582). The mean AC cell grade reduction for patients in group A was similar to that in group B (2.52 vs 2.86 respectively; P=0.92). Group A patients showed significantly lower corneal fluorescein staining scores (P < 0.001) and reported milder subjective ocular discomfort (0.55 vs 1.43, P= 0.01) as compared with group B.

The authors conclude that both preparations demonstrate equal anti-inflammatory effects for the treatment of AAU, however nonpreserved methylprednisolone eye drops exhibited a significantly lower ocular surface toxicity profile and milder subjective discomfort when compared with that exhibited by preserved prednisolone.

My comment:

Aggressive treatment for AAU, especially in the first few hours and days, is now standard, but this can result in ocular surface epitheliopathy from the preservatives. As we all know, the best treatments are both therapeutically effective and have minimal side effects. The latter is critical to patient compliance. This small study demonstrates the effectiveness and safety of non-preserved compared to preserved steroid drops in the treatment of AAU. The preservative-free option is much more expensive for our patients, but it is very easy to give our patients a couple of minims that they can use over the first couple of hours. Less toxic and gets them off to a good start until they get to the chemist!

Low dose doxycycline

Treatment of Ocular Rosacea with Once-Daily Low Dose Doxycycline

Sobolewska B, Doycheva D, Deuter C, et al. Cornea 2014; 33:257-260

This retrospective case series looked at 15 patients with ocular rosacea enrolled between February 2010 and October 2012. The aim of the study was to determine the efficacy of once-daily systemic treatment of ocular rosacea with a slow-release form of 40mg of doxycycline. Patient complaints and clinical findings including blepharitis with telangiectasia and meibomian gland dysfunction, conjunctival redness, and fluorescein staining of the cornea were assessed. The mean duration of treatment was 8 months (range, 5-12 months), and the mean duration of follow-up was 9 months (range, 6-17 months).

At baseline, 73.3% of patients had severe complaints, and 80% had severe blepharitis despite topical therapy with artificial tears and eyelid hygiene. After 12 weeks of systemic treatment, only 13.3% had severe complaints and only 20% had severe blepharitis (P=0.01). Follow-up investigations 6 to 17 months after treatment discontinuation showed further significant improvement of complaints (absent or mild in 66.7% and 20% of the patients, respectively) and blepharitis (absent or mild in 26.7% and 60% of the patients, respectively). One patient had a mild stomach ache so therapy was shortened to 5 months.

The authors conclude that an anti-inflammatory dose of slow-release doxycycline 40mg daily may be an effective and safe therapy of ocular rosacea.

My comment:

It’s good to get confirmation of our impression that doses lower than 50mg per day are effective in the treatment of ocular rosacea. We want to get the dose well below that which will cause systemic effects and antibiotic resistance. I made another plea to Pharmac last month to fund a 25mg tablet. Fingers crossed!

What’s the problem?

Our Advances are Fabulous. Then what is the Problem?

Brown GC and Busbee BG. Curr Opin Ophthalmol 2014; 25:155-157

This editorial highlights the fact that over the last 10 years there have been huge leaps in ophthalmic treatments, intravitreal vascular endothelial growth factor (VEGF) inhibitors for the treatment of neovascular age-related macular degeneration, branch and central retinal vein occlusion and diabetic retinopathy; cataract surgery and glaucoma surgery to say the least. Ophthalmic interventions yield a considerable financial return-on-investment (ROI) to society for the direct medical costs expended. The most commonly performed ophthalmic procedures provide a 15-20% gain in life’s value, versus approximately an 8% value gain for the 800 interventions across medicine that have been analysed at the Centre for Value-Based Medicine. The problem is – relatively few of our colleagues in the medical or general community know about the great advances, and where they do know, they have little concept of the great patient value they provide, much less the financial ROI.

How do they know this? Preference-based (utility) quality-of-life (QOL) studies in the USA have demonstrated that patients with 20/200 vision or worse have a similar quality-of-life associated with renal dialysis, severe angina or a Rankin 4 stroke with marked paralysis. The general public equated the same level of vision loss to the QOL experienced by patients with gout or hyperthyroidism. Non-ophthalmic physician clinicians equated the same level of vision loss to the QOL experienced by patients with migraine headaches or rheumatoid arthritis of the hip. Medical students perceived it to be similar to that perceived by the general public.

What does this mean for us and our patients? Our colleagues may not realise that patients with severe vision loss have difficulty in taking their medications, may be unable to clean their homes appropriately, may have difficulty with personal hygiene, may be depressed, may have a poor diet because of an inability to shop and cook nutritious meals, may be unable to take care of their finances, may have difficulty obtaining transport to and from appointments, and so on. These issues can all affect systemic health. Non-ophthalmic physicians are more likely to be involved in the allocation of medical resources, therefore if they do not associate blindness with a poor QOL this can result in less funding going into ophthalmology. If the field of ophthalmology is not perceived as providing substantial benefit to patients, it may attract less talented medical students than other specialties.

What can we do about this? Educate our medical colleagues and the general public. Encourage the positive perception of the benefits and advances of our field. The advances have been monumental, but without education about them, future advances may be less than they could be.

My comment:

Eye care professionals provide some of the greatest benefits to patients’ quality of life compared to other professions. In order to keep progressing at the rate we have been, it’s important that other people know of the advances and benefits of our treatments. So start talking!

Topical tacrolimus in VKC

Topical Tacrolimus 0.03% as Sole Therapy in Vernal Keratoconjunctivitis: A Randomized Double-Masked Study

Müller GG, José NK, de Castro RS. Eye & Contact Lens 2014; 40:79-83

This prospective, randomised, double-masked trial evaluated 21 patients with severe vernal keratoconjunctivitis (VKC) to examine the efficacy of the use of tacrolimus alone compared with the use of combined tacrolimus and olopatadine for treatment. One group was treated with 0.03% tacrolimus ointment combined with 1% olopatadine ophthalmic solution and the other with 0.03% tacrolimus ointment combined with placebo eye drops. Clinical signs and symptoms were graded and the efficacy of treatment was determined by the difference between the score at baseline and after 30 days of treatment. The clinical impression of improvement as perceived by the evaluator and the self-assessment provided by the patient were scored at day 30 of treatment and compared between the groups.

Results showed a decrease in symptom scores between the assessments for both groups (-1.7 + 3.9 in the experimental group; -0.6 + 1.6 in the control group), with no significant difference between groups (P=0.205). The scores for clinical signs decreased between assessments in the experimental group (-1.1 + 2.7) and increased in the control group (0.3 + 0.9) but with no significant differences (P=0.205). There was no significant difference between the groups regarding the self-assessment (P=0.659) and the clinical impression of the evaluator (P=0.387).

The authors conclude that the isolated use of tacrolimus and the combined use of tacrolimus and olopatadine seems to have the same efficacy, although controlled studies with larger samples are needed to confirm this hypothesis.

My comment:

Severe VKC often requires treatment with steroids, ideally only for a short term, to get things under control or when symptoms flare. However, in some cases it is not possible to withdraw the steroid treatment totally. Long-term steroid treatment increases the risk of the patient developing problems such as cataract, glaucoma, and corneal complications. This small study indicates that the immunomodulator tacrolimus alone may be as effective as tacrolimus combined with olopatadine, but larger studies are still needed. However, if the isolated treatment does prove to be as effective as the combined treatment, its use will contribute towards minimising the exposure of the ocular surface to excessive amounts of potentially cytotoxic preservatives and drugs.

High myopia and POAG

Progress in Understanding the Association Between High Myopia and Primary Open-Angle Glaucoma

Ma F, Dai J, Sun X. Clin Exp Ophthalmol 2014; 42: 190-197

It has been shown by many studies that high myopia (HM) and glaucoma are closely associated. In particular, the occurrence and progression of primary open-angle glaucoma (POAG) interacts with the progression of HM. Two hypotheses have been proposed explaining the association between the two disorders: the hypertension gene theory and the collagen-related gene theory. HM and POAG show similar collagen changes and hypersensitive responses to glucocorticoids. These common features may hold key information regarding the underlying mechanisms of HM and POAG. Advances in life sciences such as molecular genetics provide opportunities for clarifying their association at the molecular level. This article reviews available research on the association between these two disorders from the perspectives of epidemiology, clinical manifestation, diagnosis and pathogenic mechanisms.

My comment:

This review article is worth a read in its entirety. It outlines the association between HM and POAG epidemiology, clinical manifestations and characteristics, diagnosis and differentiation, pathogenic mechanisms and genetic theories. It concludes that HM and POAG are widely considered to be “separate but interacting disorders” but the authors suggest they may be different manifestations and stages of one disease. The more we understand about the relationship between the disorders, the better for early diagnosis, intervention and improved quality of life for patients.