Determination of the Standard Visual Criterion for Diagnosing and Treating Presbyopia According to Subjective Patient Symptoms.

Presbyopia treatments using various modalities have been developed recently; however, no standard criteria exist for the diagnosis and treatment endpoint. This study assessed the relationship between the near visual acuity (NVA) and the subjective symptoms of phakic presbyopia and determined the numerical NVA threshold to diagnose phakic presbyopia and evaluate the effectiveness of presbyopia treatment. The binocular distance, NVA with habitual correction, and monocular conventional VA were measured. Patients were asked about their awareness of presbyopia and difficulty performing near tasks. This prospective observational study included 70 patients (mean age, 56 years; range, 32-77). Most patients became aware of presbyopia in their late forties, although some had difficulty with vision-related near tasks before becoming aware of presbyopia. Eighty three percent of patients (20/24) experienced difficulty with near vision-related tasks even with excellent NVA at 40 cm with habitual correction of 0.0 logMAR (20/20 in Snellen VA). In conclusion, the current study showed that patients became aware of presbyopia in their late forties, although some had difficulty with near vision-related tasks before becoming aware of presbyopia. Further investigation should include the proposal of appropriate diagnostic criteria for presbyopia and better management for patients with presbyopia.

Infectious keratitis after corneal crosslinking for keratoconus caused by levofloxacin-resistant microorganisms.

INTRODUCTION: We present seven cases of infectious keratitis after corneal crosslinking (CXL) to attenuate keratoconus progression. METHODS: Of 524 consecutive patients who underwent CXL, 7 cases (4 males and 3 females; 21.5 ± 7.1 years) developed postoperative infectious keratitis were retrospectively reviewed. CXL was performed using the Dresden protocol or an accelerated protocol involving epithelial removal. RESULTS: All cases appeared normal on the day after surgery, but subsequently developed eye pain, blurred vision, corneal infiltration, inflammation of the anterior chamber, and ciliary injection on day 2 or 3. Methicillin-resistant Staphylococcus aureus was cultured from two eyes, methicillin-sensitive Staphylococcus aureus from two eyes, and Streptococcus pneumoniae from one eye. All detected bacteria were resistant to levofloxacin (LVFX). Five of the seven cases, especially four of the five severe cases with hypopyon, had a history of atopic dermatitis. All cases were observed after 2015. CONCLUSIONS: Infectious keratitis after CXL caused by microbes resistant to LVFX is increasing. In addition to careful postoperative observation of the cornea, preoperative evaluation of bacteria within the conjunctival sac evident on nasal swab cultures may be useful to identify potentially problematic microbes and inform the selection of appropriate antibiotics.

Short-Term Efficacy and Safety of Cataract Surgery Combined with Iris-Fixated Phakic Intraocular Lens Explantation: A Multicentre Study.

The purpose of this study was to evaluate the short-term efficacy and safety of cataract surgery for patients with iris-fixated phakic intraocular lenses (pIOLs). This study included 96 eyes of 91 patients. The changes in the logMAR uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), subjective spherical equivalent (SE), astigmatism, and endothelial cell density (ECD) were collected retrospectively. The intraoperative and postoperative complications also were investigated to assess the surgical safety. The preoperative UCVA and BCVA improved significantly at month 1 postoperatively, respectively (p < 0.001 for both comparisons). The efficacy and safety index at month 1 postoperatively were 1.02 ± 0.56 and 1.31 ± 0.64, respectively. The SE at month 1 postoperatively was significantly (p < 0.001) higher compared to preoperatively, whereas the subjective astigmatism did not differ significantly (p = 0.078). The ECD significantly decreased at month 1 (p < 0.001). The most common postoperative complication was intraocular pressure elevation exceeding 25 mmHg in 10.4% of eyes, which was controlled with medications in all cases until month 1 postoperatively. No intraoperative complications developed. Cataract surgeries for patients with iris-fixated pIOLs were performed safely with good visual outcomes.

The Early Effects of Alcohol Consumption on Functional Visual Acuity, Tear Functions, and the Ocular Surface.

PURPOSE: We investigated the early effects of alcohol intake on tear functions and ocular surface health in this prospective controlled study. METHODS: Forty-four eyes of 22 subjects (17 males, 5 females; mean age: 35.3 years) who drank 200 mL of 25% Japanese vodka and 44 eyes of age- and sex-matched 22 control subjects who drank water were investigated. Subjects were requested to refrain from alcohol consumption from the previous day and food ingestion 6 hr before the study. Each subject consumed exactly the same order prepared dinner and same quantity of alcohol over the same time frame. Subjects underwent breath alcohol level, tear evaporation and blink rate, tear lipid layer interferometry, tear film break-up time (BUT), fluorescein and Rose Bengal stainings, Schirmer test, and visual analog scale (VAS) evaluation of dry eye symptoms before, as well as 2 and 12 hr after alcohol intake. RESULTS: The mean breath alcohol level was significantly higher in the alcohol group compared to the water group at 2 and 12 hr (P<0.001). The mean tear evaporation increased significantly from 2.5×10-7 to 8.8×10-7 gr/cm2/sec 12 hr after alcohol intake (P<0.001). The mean BUT shortened significantly from 15.0±5.0 to 5.0±2.5 sec 12 hr after alcohol intake. Lipid layer interferometry showed signs of tear film thinning 12 hr after alcohol intake in all subjects of the alcohol intake group, which was not observed in the water group. The mean blink rates increased significantly from 10.6±1.5 blinks/min to 13.5±0.9 blinks/min and 15.1±1.2 blinks/min at 2 and 12 hr, respectively, in the alcohol group (P<0.001). The Schirmer test values decreased significantly 12 hr after alcohol intake (P<0.001). The mean VAS score for dryness increased from baseline significantly in the alcohol group at 12 hr (P<0.001). No significant time-wise changes in tear functions were observed in the water group. CONCLUSION: The tear film and ocular surface epithelia showed early and distinctive quantitative and qualitative changes associated with visual disturbances after alcohol intake.

Clinical outcomes of KeraVio using violet light: emitting glasses and riboflavin drops for corneal ectasia: a pilot study.

BACKGROUND/AIMS: We developed a novel technology consisting of violet light (VL)-emitting glasses and defined the combination of VL irradiation and riboflavin treatment as KeraVio. Our goal was to evaluate the clinical results of KeraVio in patients with progressive corneal ectasia. METHODS: Eyes were exposed to VL (375 nm, irradiance 310 µW/cm2)-emitting glasses for 3 hours daily for 6 months, and a riboflavin solution was administered onto the corneal epithelium six times during each 3-hour VL irradiation. The primary end point was a change in the maximum keratometry (Kmax) value over 6 months compared with that over the 1 year before baseline. RESULTS: The efficacy of KeraVio was evaluated in 20 eyes with severe progression, and its safety was evaluated in all 40 eyes. The mean changes in Kmax over the 1 year before baseline and during the 6-month observation period were 6.03±3.41 dioptres (D) and -0.81±3.34 D, respectively (p=0.002). At 6 months, the Kmax value decreased by more than 2 D in 4 eyes (20%), remained within 2 D in 13 eyes (65%), and increased by 2 D or more in 3 eyes (15%). The corneal stromal demarcation line was identified in 16 eyes (80%), and its depth was 206.3±54.9 µm at 1 month. No significant decrease in endothelial cell density, lenticular opacity or transient corneal haze was noted. CONCLUSION: Based on our 6-month results, daily treatment of progressive corneal ectasia with KeraVio can halt disease progression without any safety concerns. CLINICAL TRIAL REGISTRATION NUMBER: jRCTs032180217.

Subjective Happiness and Satisfaction in Postoperative Anisometropic Patients after Refractive Surgery for Myopia.

Laser-assisted in situ keratomileusis (LASIK) contributes to increased patient happiness one month after surgery; however, longer term effects are unknown. We performed a retrospective cross-sectional study on 472 patients who underwent bilateral LASIK surgery to measure happiness and satisfaction with LASIK, and to identify affecting factors. Patients completed questionnaires on satisfaction with the surgery and the subjective happiness scale (SHS) before, and 1, 3, 6, and 12 months after surgery. Multiple regression analyses were performed to determine independent predictors of SHS and satisfaction scores. Mean SHS increased at one month but was similar to baseline levels by six months. The SHS of older patients was greater than younger ones at baseline and at one and three months, while satisfaction among the older group was poorer at one and three months. Multiple regression analyses revealed that the decrease in SHS score from one month to three months correlated with baseline SHS, SHS at one month, uncorrected distance visual acuity (UDVA), and age. Regression analysis revealed SHS at six months correlated with preoperative SHS, SHS at one month, and satisfaction at six months. Satisfaction at final visit correlated with age, UDVA, anisometropia, and with SHS at each visit. We conclude that happiness and satisfaction were age- and UDVA-dependent, and anisometropic patients report poorer satisfaction scores.

Tear Film Osmolarity Measurement in Japanese Dry Eye Patients Using a Handheld Osmolarity System.

We studied the efficacy and safety of a handheld osmolarity measurement system (I-PEN) in Japanese patients with dry eye disease (DED) and non-DED subjects. In this prospective, multicenter study, tear osmolarity was examined using the I-PEN in a total of 122 eyes divided into DED (n = 71) and non-DED (n = 51) groups. Subjective symptoms were assessed using the Dry Eye-Related Quality-of-Life Score (DEQS) questionnaire. Ocular surface condition was evaluated in terms of fluorescein tear breakup time (FBUT) and tear breakup pattern (TBUP), and by fluorescein staining and Schirmer's test. The I-PEN measurements were performed safely in the majority of cases. There was no statistically significant difference in mean tear film osmolarity between the DED and non-DED groups (294.76 ± 16.39 vs. 297.76 ± 16.72 mOsms/L, respectively, p = 0.32). No significant correlations were observed between osmolarity values and DEQS score, FBUT, or the Schirmer score. Osmolarity did not differ among TBUP subgroups. This prospective clinical study found no correlations between the tear film osmolarity values obtained with the I-PEN system and any subjective or objective parameters of DED. Further studies are required to determine the utility of the I-PEN system in other settings.

A Multicenter Study on Early Outcomes of Small-Incision Lenticule Extraction for Myopia.

This study was aimed to investigate the early clinical outcomes of small-incision lenticule extraction (SMILE) to correct both myopia and myopic astigmatism at major clinical centers in Japan. This case series consisted of two hundred fifty-two eyes of 130 consecutive patients who underwent SMILE surgery (29.5 ± 6.3 years, mean age ± standard deviation), with spherical equivalents of -4.33 ± 1.61 D. We determined the safety, efficacy, predictability, stability, and adverse events of this procedure. Corrected distance visual acuity significantly improved, from -0.18 ± 0.04 preoperatively to -0.19 ± 0.07 logMAR postoperatively (paired t-test, p < 0.001). Uncorrected distance visual acuity also significantly improved, from 1.05 ± 0.26 preoperatively to -0.15 ± 0.11 logMAR postoperatively (p < 0.001). 88% and 98% of eyes were within ± 0.5 and 1.0 D of the targeted correction, respectively. Changes in manifest spherical equivalent from 1 week postoperatively were 0.02 ± 0.35 D (p = 0.127). No vision-threatening complications were observed in any of the cases. SMILE performed well in the correction of myopic refractive errors, and we experienced no severe complications in this series, indicating its feasibility as a surgical option for the treatment of these eyes.

Dry Eye After LASIK.

Post-LASIK dry eye is the most common postoperative dry eye after ophthalmic surgeries. The clinical signs of post-LASIK dry eye include positive vital staining of the ocular surface, decreased tear breakup time and Schirmer test values, reduced corneal sensitivity, and decreased functional visual acuity. The symptoms and signs usually last for about 1 month after LASIK. A small number of patients continue to experience symptoms more than 1 year postoperatively. It has been suggested that the loss of corneal innervation caused by flap-making is the major cause, affecting the corneal-lacrimal gland, corneal-blinking, and blinking-meibomian gland reflexes, resulting in decreased aqueous and lipid tear secretion and mucin expression. A new type of corneal refractive surgery, SMILE, which has less impact on corneal nerves, induces less postoperative dry eye, supporting the association between corneal denervation and postoperative dry eye. As LASIK enhancement by flap-lifting induces fewer dry eye symptoms and signs than initial surgery, factors other than neurotrophic effects may be involved in the mechanisms of post-LASIK dry eye. Post-LASIK ocular surface pain is a type of postoperative chronic pain and discomfort, and is thought to be a different clinical entity from dry eye, possibly induced by abnormal reinnervation or neural sensitization of peripheral nerves and the central nervous system after LASIK. Treatments include tear supplements, anti-inflammatory agents, meibomian gland dysfunction management, ointment and eye patches, punctal plugs, and autologous serum eye drops. For patients with preoperative dry eye, careful patient selection, and preoperative ocular surface management are mandatory.

Patients' satisfaction and subjective happiness after refractive surgery for myopia.

PURPOSE: The purpose of this study was to assess patients' satisfaction and change in subjective happiness after laser-assisted in situ keratomileusis (LASIK). PATIENTS AND METHODS: This was a retrospective cross-sectional study of 307 patients (mean age, 34.3 years; range, 20-63 years) who underwent bilateral LASIK surgery and ocular examinations, including subjective refraction and visual acuity axial length measurements at Minamiaoyama Eye Clinic. Patients also completed questionnaires on their satisfaction with the surgery, and on the subjective happiness scale (SHS) within 1 month before and 1 month after surgery. A multiple regression analysis was performed to determine the independent predictors of the SHS score. RESULTS: In total, 91.2% of the patients were satisfied with surgery (very satisfied: n=155; satisfied: n=125). The SHS score increased postoperatively from 5.2±0.9 to 5.3±0.9 (P<0.001). The multiple regression analysis revealed that the preoperative SHS score (ß=0.77; P<0.001) and satisfaction with surgery (ß=-0.11; P=0.05) were predictors of postoperative SHS score. CONCLUSION: LASIK may contribute to increased patient happiness.

Corneal crosslinking for keratoconus in Japanese populations: one year outcomes and a comparison between conventional and accelerated procedures.

PURPOSE: We retrospectively investigated the efficacy of corneal crosslinking (CXL) on progressive keratoconus in a Japanese population and compared the outcomes of conventional and accelerated CXL. STUDY DESIGN: A retrospective cohort study METHODS: A total of 108 consecutive eyes in 95 patients (75 men; 21.9 ± 6.2 years) with progressive keratoconus were enrolled. The epithelium was ablated in all eyes. After presoaking the corneal stroma in riboflavin, UV-A was irradiated at 3.0 mW/cm2 (conventional CXL) for 30 min on 23 eyes and 18.0 mW/cm2 for 5 min (accelerated CXL) on 85 eyes. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, keratometric value, corneal thickness, corneal endothelial cell density (ECD), intraocular pressure, and complications were evaluated at 1, 3, 6, and 12 months after the procedure. RESULTS: BSCVA, manifest refraction, ECD, and corneal thickness did not change significantly after both procedures. The keratometric value was significantly decreased from the preoperative value at 12 months (p < 0.001). Progression to more than 1.0 D after CXL was observed in 10 eyes (9.3%). The ΔKmax was negatively associated with preoperative Kmax (p < 0.001) and positively associated with preoperative thinnest corneal thickness (p < 0.001). Both treatment modules showed no significant difference in all parameters. CONCLUSION: CXL was as effective in treating keratoconus in Japanese patients as in individuals of other ethnicities. Overall, CXL could be performed using either the conventional or accelerated approach to halt the progression of keratoconus in Japanese populations.

Amnwiotic Membrane Transplantation as a Treatment for Sterile Infiltration and Corneal Melting after Corneal Crosslinking for Keratoconus.

We report a case of corneal melting through sterile infiltration presumably due to excessive use of nonsteroidal anti-inflammatory eye drops after corneal crosslinking (CXL). It was treated using steroids combined with amniotic membrane transplantation (AMT). A 33-year-old man with progressing keratoconus underwent left eye CXL. We prescribed betamethasone and levofloxacin eye drops 5 times daily and diclofenac sodium eye drops 3 times daily for 3 days. Three days after CXL, there was a persistent epithelial defect and the left corneal stroma was clouded. His visual acuity remained unchanged. We prescribed betamethasone hourly and 20 mg prednisolone daily. At 1 week after CXL, the corneal epithelial defect and infiltration were unchanged. He had not stopped using diclofenac at the prescribed time. On day 17, we performed AMT and his cornea and visual acuity improved. AMT may be effective against persistent epithelial defects and corneal melting after CXL.

Comparative analysis of the visual and refractive outcomes of a refractive segmented multifocal intraocular lens with and without toricity: 1-year results.

PURPOSE: To compare the visual and refractive outcomes up to 1 year postoperatively following implantation of a refractive segmented or a refractive segmented toric multifocal intraocular lens (IOL). METHODS: This retrospective study included 108 eyes of 64 patients who underwent cataract surgery with implantation of a refractive segmented multifocal IOL (Lentis Mplus LS-313 MF30 IOL) (LM group) and 81 eyes of 49 patients with implantation of a refractive segmented toric multifocal IOL (Lentis Mplus LU-313 MF30T IOL) (LMT group). The visual and refractive postoperative outcomes and the rate of additional refractive procedures were evaluated up to 1 year postoperatively. RESULTS: The uncorrected distance visual acuity (VA) and uncorrected near VA exceeded 1.0 and 0.60 in decimal VA, respectively, and both were stable postoperative groups. The postoperative subjective refractive astigmatism was also stable and the postoperative refraction was near emmetropia in both groups. No significant differences were found in the need for additional surgical refractive procedures. CONCLUSION: The outcomes with a refractive segmented toric multifocal IOL were comparable to those with a non-toric model despite higher preoperative corneal astigmatism.

Visual Outcomes After LASIK Using Topography-Guided vs Wavefront-Guided Customized Ablation Systems.

PURPOSE: To evaluate the visual performance of two customized ablation systems (wavefront-guided ablation and topography-guided ablation) in LASIK. METHODS: In this prospective, randomized clinical study, 68 eyes of 35 patients undergoing LASIK were enrolled. Patients were randomly assigned to wavefront-guided ablation using the iDesign aberrometer and STAR S4 IR Excimer Laser system (Abbott Medical Optics, Inc., Santa Ana, CA) (wavefront-guided group; 32 eyes of 16 patients; age: 29.0 ± 7.3 years) or topography-guided ablation using the OPD-Scan aberrometer and EC-5000 CXII excimer laser system (NIDEK, Tokyo, Japan) (topography-guided group; 36 eyes of 19 patients; age: 36.1 ± 9.6 years). Preoperative manifest refraction was -4.92 ± 1.95 diopters (D) in the wavefront-guided group and -4.44 ± 1.98 D in the topography-guided group. Visual function and subjective symptoms were compared between groups before and 1 and 3 months after LASIK. RESULTS: Of seven subjective symptoms evaluated, four were significantly milder in the wavefront-guided group at 3 months. Contrast sensitivity with glare off at low spatial frequencies (6.3° and 4°) was significantly higher in the wavefront-guided group. Uncorrected and corrected distance visual acuity, manifest refraction, and higher order aberrations measured by OPD-Scan and iDesign were not significantly different between the two groups at 1 and 3 months after LASIK. CONCLUSIONS: Both customized ablation systems used in LASIK achieved excellent results in predictability and visual function. The wavefront-guided ablation system may have some advantages in the quality of vision. It may be important to select the appropriate system depending on eye conditions such as the pattern of total and corneal higher order aberrations. [J Refract Surg. 2016;32(11):727-732.].

Effects of laser in situ keratomileusis on mental health-related quality of life.

PURPOSE: The aims of our study were to investigate whether laser in situ keratomileusis (LASIK) improves health-related quality of life (HRQoL) and to identify factors that affect postoperative HRQoL. MATERIALS AND METHODS: A total of 213 Japanese patients who underwent primary LASIK were analyzed in this study. The average age of patients was 35.0±9.4 years. The subjects were asked to answer questions regarding subjective quality of vision, satisfaction, and quality of life (using the Japanese version of 36-Item Short Form Health Survey Version 2) at three time points: before LASIK, 1 month after LASIK, and 6 months after LASIK. Longitudinal changes over 6 months in the outputs of mental component summary (MCS) score and the physical component summary (PCS) score from the 36-Item Short Form Health Survey Version 2 questionnaire were compared between time points using a linear mixed-effects model. Delta MCS and PCS were calculated by subtracting the postoperative score (1 month after LASIK) from the preoperative score. Preoperative and postoperative factors associated with a change in the MCS score or PCS score were evaluated via a linear regression model. RESULTS: The preoperative MCS score was 51.0±9.4 and increased to 52.0±9.8 and 51.5±9.6 at 1 month and 6 months after LASIK, respectively, and the trend for the change from baseline in MCS through 6 months was significant (P=0.03). PCS score did not change following LASIK. Delta MCS was significantly negatively associated with preoperative spherical equivalent, axial length, and postoperative quality of vision, after adjusting for potential confounding factors. CONCLUSION: Mental HRQoL is not lost with LASIK, and LASIK may improve mental HRQoL. Preoperative axial length may predict postoperative mental HRQoL.

Efficacy of Hyperopic Photorefractive Keratectomy Simultaneously Performed With Phototherapeutic Keratectomy for Decreasing Hyperopic Shift.

PURPOSE: To investigate the efficacy of hyperopic photorefractive keratectomy (HPRK) that was performed simultaneously with phototherapeutic keratectomy (PTK) with regard to decreasing hyperopic shift. METHODS: A total of 63 eyes of 47 consecutive patients with granular corneal dystrophy (GCD) or band-shaped keratopathy (BSK) underwent PTK or PTK + HPRK. PTK alone was performed in 40 eyes (20 GCD and 20 BSK), and PTK + HPRK was performed in 23 eyes (15 GCD and 8 BSK). All patients underwent examinations including uncorrected distance visual acuity, corrected distance visual acuity, refractometry, and keratometry before and at 1, 3, and 6 months after PTK. Medical charts were reviewed retrospectively. RESULTS: Superficial corneal opacity was successfully removed from all eyes, and uneventful reepithelialization was completed within 7 days after PTK or PTK + HPRK. The average uncorrected distance visual acuity was significantly better in the PTK + HPRK group than in the PTK group preoperatively and at 1, 3, and 6 months postoperatively. The corrected distance visual acuities were similar in both groups preoperatively and postoperatively. The hyperopic change in the PTK group was approximately 1.5 diopters, and that in the PTK + HPRK group was almost zero. There were significant differences in the average changes of the spherical equivalent from preoperation between the PTK and PTK + HPRK groups at all postoperative time points. CONCLUSIONS: Simultaneous performance of PTK and HPRK can effectively reduce hyperopic shift after PTK and is as safe as PTK alone. It is recommended that HPRK be added to PTK to treat eyes in which hyperopic shift is undesirable.

Reducing Short-Wavelength Blue Light in Dry Eye Patients with Unstable Tear Film Improves Performance on Tests of Visual Acuity.

PURPOSE: To investigate whether suppression of blue light can improve visual function in patients with short tear break up time (BUT) dry eye (DE). METHODS: Twenty-two patients with short BUT DE (10 men, 12 women; mean age, 32.4 ± 6.4 years; age range, 23-43 years) and 18 healthy controls (10 men, 8 women; mean age, 30.1 ± 7.4 years; age range, 20-49 years) underwent functional visual acuity (VA) examinations with and without wearing eyeglasses with 50% blue light blocked lenses. The functional VA parameters were starting VA, functional VA, and visual maintenance ratio. RESULTS: The baseline mean values (logarithm of the minimum angle of resolution, logMAR) of functional VA and the visual maintenance ratio were significantly worse in the DE patients than in the controls (P < 0.05), while no significant difference was observed in the baseline starting VA (P > 0.05). The DE patients had significant improvement in mean functional VA and visual maintenance ratio while wearing the glasses (P < 0.05), while there were no significant changes with and without the glasses in the control group (P > 0.05). CONCLUSIONS: Protecting the eyes from short-wavelength blue light may help to ameliorate visual impairment associated with tear instability in patients with DE. This finding represents a new concept, which is that the blue light exposure might be harmful to visual function in patients with short BUT DE.

Preliminary report of improved sleep quality in patients with dry eye disease after initiation of topical therapy.

PURPOSE: Dry eye disease (DED) is potentially associated with sleep and mood disorders. This study evaluated sleep quality in patients with DED using a questionnaire-based survey before and after topical eyedrop treatment. The effectiveness of sleep and ophthalmic services in assisting with sleep problems in patients with eye disease was also assessed. METHODS: Seventy-one consecutive patients with DED visiting eight general eye clinics in various locations answered a questionnaire containing the Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale. Photophobia and chronotype (morningness/eveningness) were also evaluated with two representative questions from established questionnaires (National Eye Institute Visual Function Questionnaire-25 and Morningness/Eveningness questionnaire). Follow-up evaluation was conducted by interview or mail 3-10 months after the initial evaluation. A sleep service was established in two eye clinics to identify possible ocular diseases related to sleep and mood disorders; it comprised a questionnaire, sleep diary, actigram, medical interviews, visual field testing, retinal ganglion cell layer thickness measurement, and DED examination. RESULTS: Patients with newly diagnosed DED exhibited a greater improvement in sleep after DED treatment compared with patients with established DED. Improvement in Pittsburgh Sleep Quality Index was significant (P<0.05) and strongly correlated with improvement in Hospital Anxiety and Depression Scale (P<0.05) for new patients, but not for patients with established DED. Ten eye clinic patients visited the sleep service and nine of them had DED. They were successfully treated with eyedrops and sleep services, which included blue-light-shield eyewear and wearable blue-light therapy lamps according to their problem. CONCLUSION: Sleep quality improved in patients with DED after topical treatment with or without the sleep service. Psychiatric treatment focusing on sleep disorders could be beneficial for patients with DED.

Randomized, Multicenter, Double-Blind Study of the Safety and Efficacy of 1%D-3-Hydroxybutyrate eye drops for Dry Eye Disease.

In a previous study, we demonstrated that topical D-beta-hydroxybutyrate ameliorates corneal epithelial erosion and superficial punctate keratopathy in a rat model of dry eye disease. In the current investigation, we performed a prospective, randomized, multicentre, double-blind, placebo-controlled study to assess the safety and efficacy of 1% D-3-hydroxybutyrate eye drops in patients with dry eye disease. A total of 65 patients were randomly assigned to either the placebo group or the 1% D-3-hydroxybutyrate group, and the treatments were administered 6 times a day for 4 weeks. We then evaluated corneal fluorescein staining, corneal and conjunctival rose Bengal staining, tear film break-up time (BUT), Schirmer score, and subjective symptoms. At both 2 and 4 weeks, the corneal rose Bengal score was significantly better in the 1% D-3-hydroxybutyrate group than in the placebo group. Among patients with an initial Schirmer score of ≤5 mm, the corneal fluorescein staining score was significantly better in the 1% D-3-hydroxybutyrate group than in the placebo group at two weeks. Mild ocular symptoms occurred in both groups, and these spontaneously resolved. The present study suggested that 1% D-3-hydroxybutyrate eye drops are safe and effective in treating ocular surface disorders in patients with tear-deficient dry eye disease.