Coping with dry eyes: a qualitative approach.

BACKGROUND: Dry eye is a common problem that affects many people worldwide, reducing quality of life and impacting daily activities. A qualitative approach often used in medicine and other disciplines is used to evaluate how people with dry eye cope with this impact. METHODS: Six focus group sessions were conducted at the Singapore National Eye Centre (SNEC), premises of an eye research institute. These focus groups consist of a spectrum of dry eye sufferers (30 women, 8 men, aged 61 ± 11.8 years). Standard methods of coding followed by determination of themes were adhered to. Where classification was difficult, consensus was made between 3 assessors. RESULTS: Audio-recorded transcripts were coded in 10 themes by 3 assessors independently. Four of the themes involved traditional measures such as lid warming, cleansing, lubrication and oral dietary supplements. The other themes discovered were Traditional Chinese Medicine, modification of eye-care habits (e.g. wearing sunglasses), environmental humidity, lifestyle (e.g. sleeping habits), psychological attitude, and lastly sharing and communication. CONCLUSION: Holistic coping strategies were found to be prominent in dry eye sufferers from these focus groups, and people tend to find personalised ways of coping with the impact of dry eye on daily living.

Clinical Trial of Thermal Pulsation (LipiFlow) in Meibomian Gland Dysfunction With Preteatment Meibography.

OBJECTIVES: Thermal pulsation (LipiFlow) has been advocated for meibomian gland dysfunction (MGD) treatment and was found useful. We aimed to evaluate the efficacy and safety of thermal pulsation in Asian patients with different grades of meibomian gland loss. METHODS: A hospital-based interventional study comparing thermal pulsation to warm compresses for MGD treatment. Fifty patients were recruited from the dry eye clinic of a Singapore tertiary eye hospital. The ocular surface and symptom were evaluated before treatment, and one and three months after treatment. Twenty-five patients underwent thermal pulsation (single session), whereas 25 patients underwent warm compresses (twice daily) for 3 months. Meibomian gland loss was graded using infrared meibography, whereas function was graded using the number of glands with liquid secretion. RESULTS: The mean age (SD) of participants was 56.4 (11.4) years in the warm compress group and 55.6 (12.7) years in the thermal pulsation group. Seventy-six percent of the participants were female. Irritation symptom significantly improved over 3 months in both groups (P<0.01), whereas tear breakup time (TBUT) was modestly improved at 1 month in only the thermal pulsation group (P=0.048), without significant difference between both groups over the 3 months (P=0.88). There was also no significant difference in irritation symptom, TBUT, Schirmer test, and gland secretion variables between patients with different grades of gland loss or function at follow-ups. CONCLUSIONS: A single session of thermal pulsation was similar in its efficacy and safety profile to 3 months of twice daily warm compresses in Asians. Treatment efficacy was not affected by pretreatment gland loss.

Allogeneic Umbilical Cord Plasma Eyedrops for the Treatment of Recalcitrant Dry Eye Disease Patients.

BACKGROUND: Dry eye disease is a significant disease in Singapore. While there have been studies using allogenic cord serum for the treatment of dry eye disease, treatment of dry eyes with allogenic umbilical cord plasma drops has yet to be started in Singapore. PURPOSE: To evaluate the effectiveness of umbilical cord plasma eyedrops for the treatment of recalcitrant dry eyes in a local Singaporean context. METHODS: This is an observational, longitudinal, interventional study for dry eye patients who did not show clear improvement after standard therapy. Patients were recruited from 2020 to 2023 from the dry eye clinic of the Singapore National Eye Center. Umbilical cord plasma was delivered frozen to patients and stored in home freezers. All participants underwent a standardized clinical evaluation for dry eye, and data were collected. RESULTS: There were 40 participants (7 males and 33 females). The duration of follow-up was 5.52 ± 1.57 months. Kerato-epitheliopathy staining score, TBUT (tear breakup time), and SPEED (Standard Patient Evaluation of Eye Dryness Questionnaire) scores significantly improved after treatment. No statistically significant improvement was found in terms of visual acuity, according to Schirmer's score. CONCLUSION: Cord plasma eye drops significantly improved kerato-epitheliopathy staining scores in recalcitrant dry eye patients. Allogeneic plasma is a promising form of treatment for recalcitrant dry eye.

Conjunctival T Cell Profile in Allogeneic Hematopoietic Stem Cell Transplant Patients after Instilling Topical Cyclosporine-A 0.1% Cationic Emulsion.

INTRODUCTION: To profile conjunctival T cell populations in allogeneic hematopoietic stem cell transplant (HSCT) patients after instillation of daily topical cyclosporine-A (CsA) 0.1% cationic emulsion (Ikervis), and to evaluate patients' tolerance to these eye drops. METHODS: Nineteen participants were prescribed Ikervis prophylaxis once daily to both eyes from 3-5 weeks pre-HSCT to 12 months post-HSCT. The outcome measure was conjunctival T cell proportions from flow cytometry after impression cytology. Covariates included visual acuity, intraocular pressure, slit lamp and fundal examination, dry eye (SPEED) and quality of life questionnaires, non-invasive keratograph tear break-up time (NIKBUT), conjunctival redness, meibography, lipid thickness, Schirmer test, tear cytokines, fluorescein staining, tear osmolarity, and meibomian gland expressibility. RESULTS: The conjunctival T cell analysis showed either stable or decreased proportions of conjunctival CD4 T cells at the last visit from baseline in compliant patients. CD4 proportions were increased in non-compliant patients and in the single patient who developed ocular graft-versus-host disease (GVHD). All patients were tolerant to Ikervis but 6/19 were not compliant. In the majority of patients, vision did not affect activities of daily living. Pre- and post-HSCT up to the last study visit, there was no statistically significant change in clinical covariates. Only one participant developed ocular GVHD at 9 months post-HSCT. CONCLUSION: Superficial conjunctival T cell profile reflects compliance to daily topical Ikervis eye drops and clinical ocular surface parameters in allogenic HSCT patients. Tolerance is comparable to other formulations of topical CsA in the first 12 months. GOV IDENTIFIER: NCT04636918. URL: https://clinicaltrials.gov/ct2/show/NCT04636918?cond=ocular+Graft+Versus+Host+Disease&cntry=SG&draw=2&rank=2 .

Patient Medication Preferences for Managing Dry Eye Disease: The Importance of Medication Side Effects.

OBJECTIVES: The side effects of dry eye medications can lead to medication non-adherence and, eventually, to poor outcomes. This study aimed to quantify to what extent the side effects of dry eye disease (DED) medications (burning/stinging sensation and blurring) are important to patients compared to medication benefits or costs. METHODS: Patients diagnosed with DED were recruited at a referral eye center in Singapore (n = 139). This study utilized a Discrete Choice Experiment where patients were presented with 10 choice tasks where they were asked to choose between their current medication (or no medication), and two hypothetical medications that varied based on five attributes: duration of burning/stinging, duration of blurring, time to medication effectiveness, medication frequency, and out-of-pocket cost. The main outcomes were relative attribute importance and predicted uptake. RESULTS: Latent class logistic regressions found two groups with distinct preferences. For both classes, duration of burning/stinging (Class 1 = 23%, Class 2 = 29%) and cost (Class 1 = 24%, Class 2 = 27%) were the most important attributes while duration of blurring (Class 1 = 15%, Class 2 = 9%) was the least important. The predicted uptake of a medication increased 18 percentage-points when burning/stinging duration decreased from 2 h to a few minutes. The predicted uptake for new medications was lowest for those on medication with well-controlled symptoms and highest for those who were not on medication and could not control their symptoms effectively. CONCLUSION: This study showed that duration of burning/stinging was an important factor when choosing medications. Incorporating patient preferences in medication decisions can potentially improve patient acceptance of a treatment regimen.

Efficacy and Haematologic Toxicity of Palliative Radioligand Therapy of Metastatic Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen in Heavily Pre-Treated Patients.

BACKGROUND: Metastatic castration-resistant prostate cancer (mCRPC) remains a significant contributor to the global cancer burden. lutetium-177-prostate-specific membrane antigen radioligand therapy (177Lu-PSMA RLT) is an effective salvage treatment. However, studies have highlighted haematologic toxicity as an adverse event of concern. We report our single-centre experience of compassionate access palliative 177Lu-DOTAGA-(I-y)fk(Sub-KuE) (177Lu-PSMA I&T) with respect to efficacy and haematologic safety. METHODS: Patients with mCRPC and adequate bone marrow/liver function were included. All patients included underwent baseline and response assessment by Gallium-68-PSMA-11 positron emission tomography/computed tomography (68Ga-PSMA-11 PET/CT). Prescribed activity of therapy was a median 6.24 GBq per patient per cycle (IQR1.29 GBq), administered in 8-week intervals, up to four cycles. Response was assessed by prostate specific antigen (PSA) and a week-12 PET/CT. Incidence of grade ≥ 3 haematologic toxicity, including association with risk factors (age ≥ 70 years, prior/concurrent therapy, presence of metastases, and number of cycles completed), was analysed. RESULTS: One hundred patients completed one cycle of 177Lu PSMA I&T and underwent response assessment by both PSA and PET/CT. Two patients had an uninterpretable week-12 PET/CT. Median age was 70 (50-89), median number of prior therapies was three (1-6), and median follow up was 12-months. Fifty-four percent achieved a PSA response. Disease control rate (DCR) by PET/CT was 64% (29% SD, 34% PR, and 1% CR). Disease control by PET/CT was associated with an improved one-year overall survival (OS) compared to non-responders, median OS not-reached vs 10-months (p < 0.0001; 95% CI: 0.08-0.44). Regarding haematologic toxicity, 11% experienced a grade ≥ 3 cytopenia (self-limiting). No cases of myelodysplasia/acute leukaemia (MDS/AL) have been recorded. No association with risk factors was demonstrated. CONCLUSION: 177Lu-PSMA I&T is a safe and effective palliative outpatient treatment for mCRPC. 68Ga-PSMA-11 PET/CT response is associated with an improved one-year OS and may be used to adapt therapy.

Satisfaction and convenience of using terpenoid-impregnated eyelid wipes and teaching method in people without blepharitis.

PURPOSE: Demodex infestations cause blepharitis and are difficult to treat. Recently, a new type of eyelid wipes with terpenoids has been found effective. We aim to evaluate patient satisfaction after short-term use and compare two teaching modalities on the techniques of use. PATIENTS AND METHODS: Eligible participants were taught to use eyelid wipes (Cliradex®) by either live or online video demonstration based on random allocation. Participants used the wipes twice daily for a week. All participants had prior evaluation of socioeconomic status, dry eye symptoms, and meibomian gland features. After 1 week, competence of use was assessed by participants showing their technique to the investigator, and a questionnaire on comfort, ease, and convenience of use was administered. Higher scores indicate greater satisfaction, and these levels are compared among the two teaching modalities using chi square. RESULTS: A total of 50 participants were recruited, with a mean age of 42±16 years, and 88% of the participants were females. Overall, median comfort level was 4.0 (range: 1-6), ease level was 5.0 (3-6), and convenience level was 5.0 (2-6). Median stinging was 2.0 (1-4), which corresponded to some but mild stinging. The median competence level was 4.0 (2-4), which corresponded to excellent competence. These satisfactory levels (ease, comfort, and convenience) experienced were not significantly associated with different socioeconomic indicators, that is, housing type, income, highest education level, and were not different between teaching methods (p>0.05). CONCLUSION: Short-term use of Cliradex eyelid wipes seems to be acceptable to most people. The teaching instructions before using these wipes were equally effective - whether live or online video demonstration was used.

Salvage Radiopeptide Therapy of Advanced Castrate-Resistant Prostate Cancer with Lutetium-177-Labeled Prostate-Specific Membrane Antigen: Efficacy and Safety in Routine Practice.

BACKGROUND: Prostate-specific membrane antigen (PSMA)-based radiopeptide/radioligand therapy represents a rapidly expanding field in the management of metastatic castrate-resistant prostate cancer (mCRPC). However, there remains concern for the development of significant toxicities in heavily pretreated patients. In this study, the authors present their local experience, with respect to efficacy and toxicity, of 22 consecutive patients treated with lutetium-177-DOTAGA-(I-y)fk(Sub-KuE) or 177Lu-PSMA I&T radioimmunotherapy for progressive mCRPC, followed up over 1 year. MATERIALS AND METHODS: All patients had progressive mCRPC, an European Cooperative Oncology Group (ECOG) ≤2 with adequate bone marrow and liver function. 177Lu-PSMA I&T therapy was administered at 8-week intervals with a mean prescribed activity of 5.5 GBq (gigabecquerel) per patient. RESULTS: Twenty patients had evaluable results, median age of 71 years, and median duration of follow-up of 17 months. Three patients (15%) experienced a G1/2 myelotoxicity and four (20%) G3/4. No incidences of myelodysplasia/acute leukemia have been identified. All toxicities were self-limiting. Baseline cytopenia was predictive of the development of subsequent G3/4 myelotoxicity (p = 0.0035). Eight patients (40%) experienced an objective PSA response, with a median time to response of 15 weeks. The median time to PSA progression was not reached. Patients receiving three cycles of therapy were statistically more likely to experience a disease response when compared to those treated with one, two, or four cycles (p < 0.0001). CONCLUSIONS: 177Lu-PSMA I&T radioimmunotherapy of progressive mCRPC is safe and effective with three cycles being the potential optimal number for determining long-term disease response.

Agreement of noninvasive tear break-up time measurement between Tomey RT-7000 Auto Refractor-Keratometer and Oculus Keratograph 5M.

BACKGROUND: It is difficult to standardize assessment of dry eye in different clinical settings. Increasingly, tear stability is recognized to be important for the definition and assessment of patients with dry eye. Recently, two commercially available instruments have been made available for objectively measuring noninvasive tear break-up time (NIBUT), as an indicator of tear stability: the Tomey RT-7000 Auto Refractor-Keratometer and Oculus Keratograph (K)5M. We aim to assess the agreement of NIBUT measurements using these modalities. METHODS: This prospective cross-sectional study was carried out in a tertiary referral eye center and involved 126 consecutive dry eye patients. NIBUT assessment was performed on the right eyes of participants with both the RT-7000 and the K5M techniques, with the order of assessment randomized. The Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaires were administered to assess dry eye symptoms in the 2 weeks before assessment. RESULTS: The age of the participants was 56.0±14.3 years (69.84% females). Measurements for both modalities were non-normally distributed (right-skewed). The median RT-7000 and K5M readings were 4.2 (range 0.1-10.0) and 6.4 (0.1-24.9) seconds, respectively. RT-7000 and K5M readings were poorly correlated (ρ=0.061, P=0.495). Intraclass correlation coefficient between the modalities was 0.187 (95% confidence interval -0.097 to 0.406). The Bland-Altman plot showed no systematic differences between the readings with these machines. The agreement between machines was not different in different SPEED categories. CONCLUSION: While there are theoretical and practical benefits of NIBUT for assessment of tear stability over dye-based methods, the agreement between the two modalities was poor. Hence, studies and trials assessing NIBUT should avoid using these modalities interchangeably for NIBUT assessment. More research is needed to improve consensus on how to determine NIBUT.

Effects of wearing a daily disposable lens on tear film: a randomised controlled trial.

PURPOSE: Contact lens-induced dry eye is commonly encountered, although its extent is not well documented with daily disposable lenses. A novel type of contact lens system incorporating moisturising agent (alginic acid) has been developed. The aim of this study was to evaluate the effect of wearing daily 2-hydroxyethyl methacrylate disposable contact lenses for seven days on tear stability, conjunctival and limbal redness and dry eye symptoms. Then, we aimed to determine whether lens solutions containing alginic acid had any influence on tear parameters. METHODS: This was a seven-day parallel group double-masked clinical trial of previous contact lens wearers, where participants were randomly assigned to wearing SEED 1dayPure moisture contact lenses with (n = 15) or without alginic acid (n = 15). Tear lipid layer thickness (LLT), non-invasive tear break-up time (NIBUT), conjunctival redness, corneal fluorescein staining, tear break-up time and Schirmer I readings were measured. Symptom severity and frequency were evaluated and combined using a global score from visual analogue scales. RESULTS: The mean age and standard deviation of the participants was 25 ± 3.8 years. There were 24 females and six males. After reintroduction of contact lens wear for one week, there was significant improvement in the global symptom score; however, this may not be clinically significant. There were small and clinically insignificant changes in limbal and conjunctival hyperaemia but no significant changes in lipid layer thickness, Schirmer I and NIBUT in overall participants. The use of alginic acid in lens solutions did not affect these parameters compared to control lenses (p > 0.05). CONCLUSIONS: After seven days of wearing a modern daily disposable lens, there was no significant deterioration of tear function in a group of young contact lens wearers. In this short-term study, there was no evidence of significant benefit of lens solutions containing alginic acid used with HEMA lenses.

Longitudinal Changes in Tear Evaporation Rates After Eyelid Warming Therapies in Meibomian Gland Dysfunction.

PURPOSE: Lid warming is the major treatment for meibomian gland dysfunction (MGD). The purpose of the study was to determine the longitudinal changes of tear evaporation after lid warming in patients with MGD. METHODS: Ninety patients with MGD were enrolled from a dry eye clinic at Singapore National Eye Center in an interventional trial. Participants were treated with hot towel (n = 22), EyeGiene (n = 22), or Blephasteam (n = 22) twice daily or a single 12-minute session of Lipiflow (n = 24). Ocular surface infrared thermography was performed at baseline and 4 and 12 weeks after the treatment, and image features were extracted from the captured images. RESULTS: The baseline of conjunctival tear evaporation (TE) rate (n = 90) was 66.1 ± 21.1 W/min. The rates were not significantly different between sexes, ages, symptom severities, tear breakup times, Schirmer test, corneal fluorescein staining, or treatment groups. Using a general linear model (repeat measures), the conjunctival TE rate was reduced with time after treatment. A higher baseline evaporation rate (≥ 66 W/min) was associated with greater reduction of evaporation rate after treatment. Seven of 10 thermography features at baseline were predictive of reduction in irritative symptoms after treatment. CONCLUSIONS: Conjunctival TE rates can be effectively reduced by lid warming treatment in some MGD patients. Individual baseline thermography image features can be predictive of the response to lid warming therapy. For patients that do not have excessive TE, additional therapy, for example, anti-inflammatory therapy, may be required.

Lost to follow-up for appointments in a dedicated dry eye clinic.

OBJECTIVE: Dry eye is a prevalent condition with significant socioeconomic burden. This study evaluates the extent and reasons for loss to follow-up (LTF) in a dedicated dry eye clinic. LTF refers to patient who discontinued visits for >2 years. METHOD: The proportion of patients LTF and the demographics in a cohort of dry eye patients (2006 to 2010) were determined. A telephone survey was prospectively conducted for patients who were LTF. RESULTS: Of 505 patients, 240 (47.5%) were LTF. Associated demographic factors for LTF were male sex, non-Chinese ethnicity, and age group <30 years old (all P<0.05). The reasons for LTF through the telephone survey (response rate 77.9%) were categorized into three broad groups, stabilized dry eye condition (47%), personal/social factors (25%) and perceived insufficiency of healthcare delivery (28%). Only two (1.1%) were considered as management failures. The younger patients (age <50 years) were more likely to become LTF (P<0.001) due to stabilized dry eye disease, compared to older patients who were more likely to be LTF due to personal/social reasons (P=0.02). Poor communication and service factors under healthcare delivery were found to be higher (P=0.002) in those who visited once before they were LTF (8.5%) compared to those who visited multiple times before they were LTF (0.1%). CONCLUSION: LTF was relatively common in hospital-based dry eye management. Female and older patients were less likely to stop consultation. Stabilized dry eye condition, common in younger patients, was the most common reason for LTF. Elderly patients have difficulty attending clinics due to nonmedical problems, which may require a more holistic approach.

A Randomized, Controlled Treatment Trial of Eyelid-Warming Therapies in Meibomian Gland Dysfunction.

AIM: The main treatment for meibomian gland dysfunction (MGD), a major cause of dry eye, is eyelid warming. Lack of compliance is the main reason for treatment failure. This has led to the development of eyelid-warming devices that are safe, effective and convenient. To obtain robust evidence demonstrating their efficacy, the authors conducted a 3-arm randomized clinical study. METHODS: The authors conducted a 3-month assessor-blinded, randomized, controlled trial of patients from the Singapore National Eye Centre experiencing at least one of eight dry eye symptoms 'often' or 'all the time'. Patients who wore contact lenses, had an active infection or known diagnosis of thyroid dysfunction and rheumatoid arthritis were excluded from the study. MGD participants were randomly assigned to warm towel (n = 25), EyeGiene(®) (Eyedetec Medical Inc., Danville, CA, USA) (n = 25) and Blephasteam(®) (Spectrum Thea Pharmaceuticals LTD, Macclesfield, UK) (n = 25) treatments. The primary efficacy and safety outcomes included the proportions of participants with improved symptoms and changes in best corrected visual acuity (BCVA), respectively. Other outcomes included tear break up time (TBUT), Schirmer test, corneal fluorescein dye staining and number of visibly occluded meibomian gland (MG) orifices. RESULTS: The study population was 53.5 ± 11.1 years old and predominantly Chinese. For severity of symptom after 3 months of treatment, 78.3% Blephasteam(®) participants reported improvement compared to 45.5% warm towel participants (p = 0.023). The corresponding proportions for improvement in the frequency of symptoms were 82.6% and 50.0%, respectively (p = 0.020). The proportions of improvement of symptoms in EyeGiene(®) patients were not significantly different from warm towel intervention. At 1 month of treatment, the crude odds ratio of improvement of severity of irritation for Blephasteam(®) compared to control was 3.0 (95% CI 0.88-10.18). However, the odds ratio adjusted by age was 5.67 (1.30-24.66). The lid-warming treatments did not significantly change the TBUT, Schirmer test results or number of visibly occluded MGs in the study period. All treatment modalities did not worsen BCVA after 3 months. CONCLUSION: Blephasteam(®) is more effective than warm towel for MGD treatment, with warm towel and EyeGiene(®) being comparable effective. Older age might predict for treatment efficacy. All studied therapies were safe for visual acuity (VA) for 3 months of treatment.