Elevated Neutrophils and reduced NK cells are associated with altered tear molecular signatures and clinical sequelae of chronic ocular Stevens-Johnson Syndrome.

PURPOSE: Stevens-Johnson syndrome (SJS) is characterised as an immuno-inflammatory condition with potentially blinding ocular sequelae. Therefore, we have investigated the ocular surface immune cell profile and correlated it with secreted tear molecular factors and clinical ocular sequelae in SJS patients. METHODS: 21 patients (42 eyes) with chronic ocular SJS and 16 healthy controls (20 eyes) were included in the study. Severity, types of keratopathies and ocular surface(OS) manifestations were determined. OS wash samples from study subjects were used to determine the status of 13 immune cell subsets using flow cytometry. Levels of 42 secreted immuno-inflammatory factors were measured by flow cytometry-based multiplex ELISA in tear samples. RESULTS: Neutrophils (Total, activated), neutrophils/NK cells ratio, neutrophils/T cells ratio were significantly (p<0.05) elevated in SJS, while, proportions of T cells and NKT cells were significantly lower in SJS patients. Positive association between neutrophils and chronic ocular surface complication score (COCS) was observed, whereas, a negative association was noted between NK cells and COCS. Tear fluid levels of IL-6, IL-8, IL-18, IFNα/ß/γ, TNFα, LIF, IL-8, HGF, sTNFR-I, NGAL, Granzyme, Perforins, MMP9/TIMP1 ratio were significantly higher in SJS. Loss of Limbal niche correlated significantly with immune profile and clinical sequelae. Increased neutrophils, decreased NK cells and specific set of altered secreted immuno-inflammatory mediators including bFGF, and IL-8 were observed in SJS patients with different types of keratopathies compared to those without keratopathy. CONCLUSION: Distinct ocular surface immune profile variations were observed to correlate with clinical stages of chronic ocular SJS. Our findings uncover novel mechanisms and potential for targeted therapy in chronic ocular SJS patients.

Private equity in radiology - Why aren't we more concerned?

There has been recent scrutiny of private equity involvement in the healthcare market by federal and state governmental agencies who are concerned about the corporatization and financialization of healthcare in the United States. Data is emerging that patient costs increase, quality of healthcare decreases, physician autonomy decreases, and physician burnout and moral injury increases when corporate interests like private equity enter the medical market. Like other medical specialties, the field of radiology has been affected by corporatization and radiologists should understand how private equity interests may affect individual radiologists and the radiology workforce on a larger scale.

Spike sign - To predict the formation of big bubble in deep anterior lamellar keratoplasty in advanced keratoconus.

Lamellar surgeries have revolutionized our understanding and practice of keratoplasties. However, the learning curve in deep anterior lamellar keratoplasty (DALK) makes it daunting for novice surgeons. This paper describes a unique intraoperative sign - the radial "spike sign," which heralds the commencement of a big bubble in some cases of advanced keratoconus in eyes that have not undergone any previous surgery. The spike sign was noted during big bubble DALK surgery and was then retrospectively looked for in recorded DALK surgical videos and correlated with the formation of a big bubble. The movement of air after injection was classified into the direct formation of a big bubble, stromal emphysema with no big bubble, and emphysema with the spike sign followed by a big bubble. In total, 104 surgical videos of big bubble attempts were evaluated and classified as such. The spike sign helps reduce the number of unnecessary attempts at big bubble formation during DALK, thus improving surgical outcomes.

The Gene Network Correlation Analysis of Obesity to Type 1 Diabetes and Cardiovascular Disorders: An Interactome-Based Bioinformatics Approach.

The current study focuses on the importance of Protein-Protein Interactions (PPIs) in biological processes and the potential of targeting PPIs as a new treatment strategy for diseases. Specifically, the study explores the cross-links of PPIs network associated with obesity, type 1 diabetes mellitus (T1DM), and cardiac disease (CD), which is an unexplored area of research. The research aimed to understand the role of highly connected proteins in the network and their potential as drug targets. The methodology for this research involves retrieving genes from the NCBI online gene database, intersecting genes among three diseases (type 1 diabetes, obesity, and cardiovascular) using Interactivenn, determining suitable drug molecules using NetworkAnalyst, and performing various bioinformatics analyses such as Generic Protein-Protein Interactions, topological properties analysis, function enrichment analysis in terms of GO, and Kyoto Encyclopedia of Genes and Genomes (KEGG), gene co-expression network, and protein drug as well as protein chemical interaction network. The study focuses on human subjects. The results of this study identified 12 genes [VEGFA (Vascular Endothelial Growth Factor A), IL6 (Interleukin 6), MTHFR (Methylenetetrahydrofolate reductase), NPPB (Natriuretic Peptide B), RAC1 (Rac Family Small GTPase 1), LMNA (Lamin A/C), UGT1A1 (UDP-glucuronosyltransferase family 1 membrane A1), RETN (Resistin), GCG (Glucagon), NPPA (Natriuretic Peptide A), RYR2 (Ryanodine receptor 2), and PRKAG2 (Protein Kinase AMP-Activated Non-Catalytic Subunit Gamma 2)] that were shared across the three diseases and could be used as key proteins for protein-drug/chemical interaction. Additionally, the study provides an in-depth understanding of the complex molecular and biological relationships between the three diseases and the cellular mechanisms that lead to their development. Potentially significant implications for the therapy and management of various disorders are highlighted by the findings of this study by improving treatment efficacy, simplifying treatment regimens, cost-effectiveness, better understanding of the underlying mechanism of these diseases, early diagnosis, and introducing personalized medicine. In conclusion, the current study provides new insights into the cross-links of PPIs network associated with obesity, T1DM, and CD, and highlights the potential of targeting PPIs as a new treatment strategy for these prevalent diseases.

Demographic profile and clinical characteristics of patients presenting with acute ocular burns.

Purpose: To study and compare the demographic and clinical profile of acute ocular burns (AOB) in children and adults. Methods: This retrospective case series included 271 children (338 eyes) and 1300 adults (1809 eyes) who presented to two tertiary eye care centers within one month of sustaining AOB. Data regarding demographics, causative agents, severity of injury, visual acuity (VA), and treatment were collected and analyzed. Results: Males were more commonly affected particularly among adults (81% versus 64%, P < 0.00001). Among children, 79% sustained domestic injuries, whereas 59% of adults had work-place injuries (P < 0.0001). Most cases were due to alkali (38%) and acids (22%). Edible lime (chuna, 32%), superglue (14%), and firecrackers (12%) in children, and chuna (7%), insecticides, lye, superglue (6% each), toilet cleaner (4%) and battery acid (3%) in adults, were the main causative agents. The percentage of cases with Dua grade IV-VI was greater in children (16% versus 9%; P = 0.0001). Amniotic membrane grafting and/or tarsorrhaphy were needed in 36% and 14% of affected eyes in children and adults, respectively (P < 0.00001). The median presenting VA was logMAR 0.5 in children and logMAR 0.3 in adults (P = 0.0001), which improved significantly with treatment in both groups (P < 0.0001), but the final VA in eyes with Dua grade IV-VI burns was poorer in children (logMAR 1.3 versus logMAR 0.8, P = 0.04). Conclusion: The findings clearly delineate the at-risk groups, causative agents, clinical severity, and treatment outcomes of AOB. Increased awareness and data-driven targeted preventive strategies are needed to reduce the avoidable ocular morbidity in AOB.

Corneal Regeneration Using Gene Therapy Approaches.

One of the most remarkable advancements in medical treatments of corneal diseases in recent decades has been corneal transplantation. However, corneal transplants, including lamellar strategies, have their own set of challenges, such as graft rejection, delayed graft failure, shortage of donor corneas, repeated treatments, and post-surgical complications. Corneal defects and diseases are one of the leading causes of blindness globally; therefore, there is a need for gene-based interventions that may mitigate some of these challenges and help reduce the burden of blindness. Corneas being immune-advantaged, uniquely avascular, and transparent is ideal for gene therapy approaches. Well-established corneal surgical techniques as well as their ease of accessibility for examination and manipulation makes corneas suitable for in vivo and ex vivo gene therapy. In this review, we focus on the most recent advances in the area of corneal regeneration using gene therapy and on the strategies involved in the development of such therapies. We also discuss the challenges and potential of gene therapy for the treatment of corneal diseases. Additionally, we discuss the translational aspects of gene therapy, including different types of vectors, particularly focusing on recombinant AAV that may help advance targeted therapeutics for corneal defects and diseases.

Artificial intelligence-based stratification of demographic, ocular surface high-risk factors in progression of keratoconus.

Purpose: The purpose of this study was to identify and analyze the clinical and ocular surface risk factors influencing the progression of keratoconus (KC) using an artificial intelligence (AI) model. Methods: This was a prospective analysis in which 450 KC patients were included. We used the random forest (RF) classifier model from our previous study (which evaluated longitudinal changes in tomographic parameters to predict "progression" and "no progression") to classify these patients. Clinical and ocular surface risk factors were determined through a questionnaire, which included presence of eye rubbing, duration of indoor activity, usage of lubricants and immunomodulator topical medications, duration of computer use, hormonal disturbances, use of hand sanitizers, immunoglobulin E (IgE), and vitamins D and B12 from blood investigations. An AI model was then built to assess whether these risk factors were linked to the future progression versus no progression of KC. The area under the curve (AUC) and other metrics were evaluated. Results: The tomographic AI model classified 322 eyes as progression and 128 eyes as no progression. Also, 76% of the cases that were classified as progression (from tomographic changes) were correctly predicted as progression and 67% of cases that were classified as no progression were predicted as no progression based on clinical risk factors at the first visit. IgE had the highest information gain, followed by presence of systemic allergies, vitamin D, and eye rubbing. The clinical risk factors AI model achieved an AUC of 0.812. Conclusion: This study demonstrated the importance of using AI for risk stratification and profiling of patients based on clinical risk factors, which could impact the progression in KC eyes and help manage them better.

Proteogenomic analysis of Serratia marcescens using computational subtractive genomics approach.

Serratia marcescens, a Gram-negative bacterium (Enterobacteriaceae) is a hospital-acquired opportunistic pathogen that infects the urinary and central nervous systems. The identification of new therapeutics against S. marcescens is crucial since it is now multi-drug resistant. Therefore, the current study was aimed to identify potential drug targets against S. marcescens strains i.e. WW4, SM39, and Db11 using comparative metabolic pathway analysis and subtractive genomics approach. The applied bioinformatics-based method was used to identify the unique metabolic pathways as the prioritized drug targets. The downstream analysis has led to the identification of three pathways that are specifically absent and/or present in the specific strain. Consequently, six proteins were identified through subtractive genomic analysis. The identified proteins were found as non-homologous and essential to the pathogen's survival as well as unique to the WW4 strain. The estimated features proposed it as a potential drug target. The selected protein was further subjected to in-depth structural analysis for the structure modeling, structure validation, and protein-protein interaction analysis. Furthermore, the library of ~1500 approved compounds was screened against selected drug target to identify potential drug candidates. The current work may help in repurposing of the drug compounds as novel medication against S. marcescens.

Role of in vivo confocal microscopy in dry eye disease and eye pain.

Dry eye disease is known to have a lot of variability in presentation with overlapping subtypes. Understanding the pathology of this condition will guide therapeutic options. In vivo confocal microscopy is a diagnostic and imaging modality that provides high magnification and high-resolution images of all layers of the cornea and ocular surface. Various structures in the cornea and their alterations due to dry eye have been imaged. The impact of the tear film instability, inflammation, and altered homeostasis on the corneal epithelium, nerves, keratocytes, and dendritic cells have been evaluated across different studies. In addition, key features of IVCM in patients with neuropathic pain have been highlighted in this paper.

Tear biomarkers in dry eye disease: Progress in the last decade.

Dry eye disease (DED) is a commonly occurring, multifactorial disease characterized by reduced tear film stability and hyperosmolarity at the ocular surface, leading to discomfort and visual compromise. DED is driven by chronic inflammation and its pathogenesis involves multiple ocular surface structures such as the cornea, conjunctiva, lacrimal glands, and meibomian glands. The tear film secretion and its composition are regulated by the ocular surface in orchestration with the environment and bodily cues. Thus, any dysregulation in ocular surface homeostasis causes an increase in tear break-up time (TBUT), osmolarity changes, and reduction in tear film volume, all of which are indicators of DED. Tear film abnormalities are perpetuated by underlying inflammatory signaling and secretion of inflammatory factors, leading to the recruitment of immune cells and clinical pathology. Tear-soluble factors such as cytokines and chemokines are the best surrogate markers of disease severity and can also drive the altered profile of ocular surface cells contributing to the disease. Soluble factors can thus help in disease classification and planning treatment strategies. Our analysis suggests increased levels of cytokines namely interleukin-1ß (IL-1ß), IL-2, IL-4, IL-6, IL-9, IL-12, IL-17A, interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α); chemokines (CCL2, CCL3, CCL4, CXCL8); MMP-9, FGF, VEGF-A; soluble receptors (sICAM-1, sTNFR1), neurotrophic factors (NGF, substance P, serotonin) and IL1RA and reduced levels of IL-7, IL-17F, CXCL1, CXCL10, EGF and lactoferrin in DED. Due to the non-invasive sample collection and ease of quantitively measuring soluble factors, tears are one of the best-studied biological samples to molecularly stratify DED patients and monitor their response to therapy. In this review, we evaluate and summarize the soluble factors profiles in DED patients from the studies conducted over the past decade and across various patient groups and etiologies. The use of biomarker testing in clinical settings will aid in the advancement of personalized medicine and represents the next step in managing DED.

Ion channels in dry eye disease.

Dry eye disease (DED) which affects millions of people worldwide is an ocular surface disease that is strongly associated with pain, discomfort, and visual disturbances. Altered tear film dynamics, hyperosmolarity, ocular surface inflammation, and neurosensory abnormalities are the key contributors to DED pathogenesis. The presence of discordance between signs and symptoms of DED in patients and refractoriness to current therapies in some patients underpin the need for studying additional contributors that can be modulated. The presence of electrolytes or ions including sodium, potassium, chloride, bicarbonate, calcium, and magnesium in the tear fluid and ocular surface cells contribute to ocular surface homeostasis. Ionic or electrolyte imbalance and osmotic imbalance have been observed in DED and feed-forward interaction between ionic imbalances and inflammation alter cellular processes in the ocular surface resulting in DED. Ionic balances in various cellular and intercellular compartments are maintained by dynamic transport via ion channel proteins present in cell membranes. Hence, alterations in the expression and/or activity of about 33 types of ion channels that belong to voltage-gated channels, ligand-gated channels, mechanosensitive ion channel, aquaporins, chloride ion channel, sodium-potassium-chloride pumps or cotransporters have been investigated in the context of ocular surface health and DED in animal and/or human subjects. An increase in the expression or activity of TRPA1, TRPV1, Nav1.8, KCNJ6, ASIC1, ASIC3, P2X, P2Y, and NMDA receptor have been implicated in DED pathogenesis, whereas an increase in the expression or activity of TRPM8, GABAA receptor, CFTR, and NKA have been associated with resolution of DED.

Ocular surface immune cell diversity in dry eye disease.

Dry eye disease (DED) is a multifactorial chronic ocular surface inflammatory condition. Disease severity has been directly related to the immuno-inflammatory status of the ocular surface. Any perturbation in the orchestrated functional harmony between the ocular surface structural cells and immune cells, both resident and trafficking ones, can adversely affect ocular surface health. The diversity and contribution of ocular surface immune cells in DED have been of interest for over a couple of decades. As is true with any mucosal tissue, the ocular surface harbors a variety of immune cells of the innate-adaptive continuum and some of which are altered in DED. The current review curates and organizes the knowledge related to the ocular surface immune cell diversity in DED. Ten different major immune cell types and 21 immune cell subsets have been studied in the context of DED in human subjects and in animal models. The most pertinent observations are increased ocular surface proportions of neutrophils, dendritic cells, macrophages, and T cell subsets (CD4+; CD8+; Th17) along with a decrease in T regulatory cells. Some of these cells have demonstrated disease-causal association with ocular surface health parameters such as OSDI score, Schirmer's test-1, tear break-up time, and corneal staining. The review also summarizes various interventional strategies studied to modulate specific immune cell subsets and reduce DED severity. Further advancements would enable the use of ocular surface immune cell diversity, in patient stratification, i.e. DED-immunotypes, disease monitoring, and selective targeting to resolve the morbidity related to DED.

Systemic investigations in dry eye disease.

The incidence of dry eye disease has increased manifold in the past few years with more patients presenting with these complaints to our clinics every day. In the more severe forms of disease, it is important to evaluate for any systemic association which could be driving the disease such as in Sjogren's syndrome. Understanding the possible varied etiopathogenesis and knowing when to evaluate, form an important part of treating this condition effectively. In addition, it is sometimes confusing as to which investigations to order and how to prognosticate the disease in these situations. This article simplifies this into an algorithmic approach with insights from the ocular and systemic point of view.

Evaporative dry eye disease due to meibomian gland dysfunction: Preferred practice pattern guidelines for diagnosis and treatment.

Evaporative dry eye (EDE) due to meibomian gland dysfunction (MGD) is one of the common clinical problems encountered in ophthalmology. It is a major cause of dry eye disease (DED) and of ocular morbidity. In EDE, inadequate quantity or quality of lipids produced by the meibomian glands leads to faster evaporation of the preocular tear film and symptoms and signs of DED. Although the diagnosis is made using a combination of clinical features and special diagnostic test results, the management of the disease might be challenging as it is often difficult to distinguish EDE from other subtypes of DED. This is critical because the approach to the treatment of DED is guided by identifying the underlying subtype and cause. The traditional treatment of MGD consists of warm compresses, lid massage, and improving lid hygiene, all measures aimed at relieving glandular obstruction and facilitating meibum outflow. In recent years, newer diagnostic imaging modalities and therapies for EDE like vectored thermal pulsation and intense pulsed light therapy have emerged. However, the multitude of management options may confuse the treating ophthalmologist, and a customized rather than a generalized approach is necessary for these patients. This review aims to provide a simplified approach to diagnose EDE due to MGD and to individualize treatment for each patient. The review also emphasizes the role of lifestyle modifications and appropriate counseling so that patients can have realistic expectations and enjoy a better quality of life.

Type 1-type 2 interferon imbalance in dry eye disease.

Purpose: Dry eye disease (DED) is characterized by altered ocular surface proinflammatory and antiinflammatory factors. Interferons (IFNs) are a class of pleiotropic cytokines well known for their antimicrobial, inflammatory, and immunomodulatory roles. Hence, this study investigates the ocular surface expression of different types of IFNs in patients with DED. Methods: The cross-sectional, observational study included patients with DED and normal subjects. Conjunctival impression cytology (CIC) samples were obtained from the study subjects (controls, n = 7; DED, n = 8). The mRNA expression levels of type 1 IFN (IFNα, IFNß), type 2 IFN (IFNγ), and type 3 IFN (IFNλ1, IFNλ2, IFNλ3) were measured by quantitative PCR (polymerase chain reaction) in CIC samples. IFNα and IFNγ expression under hyperosmotic stress was also studied in human corneal epithelial cells (HCECs) in vitro. Results: The mRNA expression levels of IFNα and IFNß were significantly lower and that of IFNγ was significantly higher in DED patients compared to healthy controls. The mRNA levels of IFNα, IFNß, and IFNλ were significantly lower compared to IFNγ in DED patients. An inverse association between tonicity-responsive enhancer-binding protein (TonEBP; hyperosmotic stress maker) and IFNα or IFNß expression and a positive association between TonEBP and IFNγ expression was observed in CIC samples. The expression of IFNα was lower than IFNγ in HCECs undergoing hyperosmotic stress compared to HCECs without the stress. Conclusion: The presence of an imbalance between type 1 and type 2 IFNs in DED patients suggests newer pathogenic processes in DED, plausible ocular surface infection susceptibility in DED patients, and potential therapeutic targets in the management of DED.

Modulation of mucin secretion using combined polyethylene glycol-propylene glycol topical formulation in a hyperosmotic stress-based explant model.

Purpose: Ocular surface discomfort and dry eye disease are caused by a dysfunctional tear film. The efficacy of lubricating eye drops on the human eye is known, but the compositions may show differential effects on rescuing the tear film. Mucins form a critical layer of the tear film, a reduction of which may be causative for ocular surface conditions. Therefore, it is essential to develop relevant human-derived models to test mucin production. Methods: Human corneoscleral rims were obtained from a healthy donor (n = 8) post-corneal keratoplasty and cultured in DMEM/F12 media. Hyperosmolar stress mimicking dry eye disease was induced by exposing the corneoscleral rim tissues to +200 mOsml NaCl-containing media. The corneoscleral rims were treated with polyethylene glycol-propylene glycol (PEG-PG)-based topical formulation. Gene expression analysis was performed for NFAT5, MUC5AC, and MUC16. Secreted mucins were measured by enzyme-linked immunosorbent assay (ELISA) (Elabscience, Houston, TX, USA) for MUC5AC and MUC16. Results: The corneoscleral rims responded to hyperosmolar stress by upregulating NFAT5, a marker for increased osmolarity, as observed in the case of dry eye disease. The expression of MUC5AC and MUC16 was reduced upon an increase in hyperosmotic stress. The corneoscleral rim tissues showed induction of MUC5AC and MUC16 expression upon treatment with PEG-PG topical formulation but did not show significant changes in the presence of hyperosmolar treatments. Conclusion: Our findings showed that PEG-PG-based topical formulation slightly alleviated hyperosmolar stress-induced decrease in MUC5AC and MUC16 gene expression that is encountered in DED.