Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs.

In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.

TFOS Lifestyle: Impact of cosmetics on the ocular surface.

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

[Ocular surface disease in glaucoma patients: Expert opinion and management algorithm in Algeria]. / Atteinte de la surface oculaire chez les patients glaucomateux : avis d'experts et algorithme de prise en charge en Algérie.

INTRODUCTION: The main goal of treatment for any glaucoma patient is to reduce the intraocular pressure. Unfortunately, the long-term use of glaucoma medications causes deleterious effects on the ocular surface, leading to impaired quality of life and failed glaucoma surgery. In addition, adverse effects of medications are a barrier to adherence and compliance, and this directly affects efficacy. It is therefore essential to regularly assess the ocular surface of glaucoma patients in order to detect any signs of damage early and act accordingly. Although the TFOS DEWS 2 now offers a strategy for diagnosing ocular surface pathologies, some examinations are unfortunately not feasible in Algeria due to lack of time and/or knowledge on the part of some ophthalmologists or are simply inaccessible to others. METHODS: Algerian experts (members of the ACOS club) met for the purpose of proposing an algorithm for the management of Algerian glaucoma patients, based on the recommendations of the DEWS, their own practice and the results of a preliminary national survey of ophthalmologists. RESULTS: The proposed algorithm allows evaluation of the ocular surface of the glaucoma patient in current practice by any Algerian ophthalmologist. CONCLUSION: Management of glaucoma patients should include a systematic examination of the ocular surface. The choice of treatment should be determined by the ocular surface condition of the glaucoma patient.

Lacrimal gland injection of platelet rich plasma for treatment of severe dry eye: a comparative clinical study.

BACKGROUND: We aimed to assess the efficacy of the injections of platelet rich plasma (PRP) for the treatment of severe dry eye disease (DED). RESULTS: In this retrospecitve interventional clinincal study, we included 28 eyes of 14 patients with severe DED who were diagnosed with Sjogren syndrome. Each patient received unilateral lacrimal gland injection of PRP at days 0, 30, 60 and 90 days while the other eye served as control group who received preservative free eye drops. We objectively assessed parameters at baseline, 1 month, 2 months and 3 months including ocular surface analyzer (OSA) namely; noninvasive tear breakup times (NIBUT), tear meniscus height (TMH), lipid layer thickness (LLT) in addition to the Schirmer test I, corneal fluorescein staining (CFS) and meiboscore. The mean age was 43.4 ± .7.85 years. Comparing different parameters, baseline data showed non-significant difference between injected eye group and control group. After 1 and 3 months of follow up, there were significant differences between both groups regarding NITBUT, TMH, LLT, CFS and Schirmer test, with p <  0.001 in favor of PRP group. CONCLUSION: Injection of PRP in lacrimal gland is simple, safe, and effective technique in treatment of severe dry eye; proved by improvement of tear film parameters through subjective and objective assessment. Further studies are needed to standardize the technique and to confirm these results.

Ocular Surface Changes in Patients with Thyroid Eye Disease: An Observational Clinical Study.

BACKGROUND: This study aimed to compare ocular surface parameter changes in active and inactive thyroid eye disease (TED) patients and controls. METHODS: This is an observational clinical study that included 60 eyes divided into three groups following clinical activity score (CAS) assessment. The first group (Group A) comprised 20 eyes with active TED (CAS score ≥3/7), while the second group (Group B) comprised 20 eyes with inactive TED (CAS score <3/7) and the third group (Group C) comprised 20 eyes of controls without dry eye manifestations. The palpebral fissure height, degree of proptosis, degree of lagophthalmos, ocular surface disease index (OSDI), Schirmer test without anesthesia, corneal fluorescein staining (CFS), non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), lipid layer thickness (LLT), meiboscore, meibomian gland dysfunction (MGD), and thyroid antibodies were assessed and data were compared between study participants. RESULTS: The mean OSDI was 40.0 ±5.80 in Group A, which significantly differed from Group B with a mean of 26.5 ±5.10 (p=0.02). There were significant differences between the two groups regarding palpebral fissure height (p=0.02), amount of proptosis (p=0.008), and degree of lagophthalmos (p=0.001). Similarly, active TED patients had more decreased tear secretion than inactive TED patients (p=0.012). Moreover, active TED patients showed a significant increase in Meibomian gland loss areas in both upper and lower eyelids compared with inactive TED patients (p=0.001). Corneal fluorescein staining also revealed a statistically significant difference between the studied groups (p=0.0001). CONCLUSION: This study showed differences regarding ocular surface parameter changes between both active and inactive TED and compared to controls. Further studies are needed to confirm these results.

Fast and sustained healing of resistant corneal ulcers using corneal scrubbing and matrix regenerating therapy.

AIM: The aim of this study was to assess the efficacy and safety of corneal scrubbing associated with matrix regenerating agent on corneal wound healing in patients with persistent corneal ulcers. METHODS: This was a retrospective case study in patients with difficult-to-treat corneal ulcer. Corneal scrubbing was performed with a sterile dry cotton bud to eliminate damaged epithelial cells and corneal deposits, promoting epithelial renewal. Regenerating agent was then administered as one eye drop every 2 days in addition to preservative-free ocular lubricants. A bandage contact lens was applied in case of moderate-to-severe corneal pain. Corneal ulcers were regularly assessed until healing. RESULTS: In total, 17 patients with a chronic corneal ulcer of various etiologies for several months on average were enrolled. Corneal scrubbing combined with regenerating agent administration led to a rapid corneal ulcer size reduction from 26.4 ± 20.6 mm2 after scrubbing (before regenerating agent) to 7.2 ± 7.1 mm2 at day 5, 3.3 ± 6.0 mm2 at day 10, and 0.9 ± 2.3 mm2 at day 18. Complete corneal ulcer healing was observed in 35.2% of patients within 10 days, in 70.4% within 18 days, and in all patients within 25 days. Corneal ulcer relapse was observed in two (11.8%) patients after 6 weeks and 5 months, respectively; both were successfully treated using the same procedure. The regenerating agent was well tolerated in all patients. CONCLUSION: In this study, combined corneal scrubbing and matrix regenerating therapy (with or without bandage contact lens) led to a rapid healing and successful resolution of persisting corneal ulcers, including large and deep corneal ulcers.

TFOS DEWS II Diagnostic Methodology report.

The role of the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) II Diagnostic Methodology Subcommittee was 1) to identify tests used to diagnose and monitor dry eye disease (DED), 2) to identify those most appropriate to fulfil the definition of DED and its sub-classifications, 3) to propose the most appropriate order and technique to conduct these tests in a clinical setting, and 4) to provide a differential diagnosis for DED and distinguish conditions where DED is a comorbidity. Prior to diagnosis, it is important to exclude conditions that can mimic DED with the aid of triaging questions. Symptom screening with the DEQ-5 or OSDI confirms that a patient might have DED and triggers the conduct of diagnostic tests of (ideally non-invasive) breakup time, osmolarity and ocular surface staining with fluorescein and lissamine green (observing the cornea, conjunctiva and eyelid margin). Meibomian gland dysfunction, lipid thickness/dynamics and tear volume assessment and their severity allow sub-classification of DED (as predominantly evaporative or aqueous deficient) which informs the management of DED. Videos of these diagnostic and sub-classification techniques are available on the TFOS website. It is envisaged that the identification of the key tests to diagnose and monitor DED and its sub-classifications will inform future epidemiological studies and management clinical trials, improving comparability, and enabling identification of the sub-classification of DED in which different management strategies are most efficacious.

Age-Related Macular Degeneration and Its Risk Factors in North Africans Living in Algeria and Italy.

PURPOSE: To determine the risk factors for age-related macular degeneration (AMD) in Algerians, and compare these data with those on North Africans living in Italy. METHODS: All patients over 55 years of age consulting one of the 23 involved Algerian ophthalmologists were invited to participate, and 1,183 patients were included. Data collection was standardized based on the Simplified Théa Risk Assessment Scale (STARS) questionnaire. A similar study was conducted in North Africans living in Italy (n = 1,011). Patients with only soft drusen and/or pigmentary abnormalities were classified as early AMD, and patients with geographic atrophy and/or neovascular AMD were classified as late AMD. RESULTS: In the final multivariate model, risk for early and/or late AMD was significantly increased with older age, family history of AMD, Black ethnicity, atherosclerosis, beer consumption, high fruit consumption, cataract surgery, myopia, and hyperopia. High consumption of green vegetables was associated with lower risk for both early and late AMD. In comparison with North Africans from Italy, Algerians generally had a healthier profile (younger, less obesity, smoking, and cardiovascular diseases, and higher consumption of fruits and vegetables) and a lower risk for AMD. CONCLUSION: This study documents risk factors for AMD in North-African populations for the first time.

Evaluation of the efficacy and safety of a standardised intracameral combination of mydriatics and anaesthetics for cataract surgery.

BACKGROUND/AIMS: To compare the efficacy and safety of intracameral (IC) administration at the beginning of cataract surgery, of Mydrane, a standardised ophthalmic combination of tropicamide 0.02%, phenylephrine 0.31% and lidocaine 1%, to a standard topical regimen. METHODS: In this international phase III, prospective, randomised study, the selected eye of 555 patients undergoing phacoemulsification with intraocular lens (IOL) implantation received 200 µL of Mydrane (Mydrane group) just after the first incision or a topical regimen of one drop each of tropicamide 0.5% and phenylephrine 10% repeated three times (reference group). The primary efficacy variable was achievement of capsulorhexis without additional mydriatics. The non-inferiority of Mydrane to the topical regimen was tested. The main outcome measures were pupil size, patient perception of ocular discomfort and safety. RESULTS: Capsulorhexis without additional mydriatics was performed in 98.9% of patients and 94.7% in the Mydrane and reference groups, respectively. Both groups achieved adequate mydriasis (>7 mm) during capsulorhexis, phacoemulsification and IOL insertion. IOL insertion was classified as 'routine' in a statistically greater number of eyes in the Mydrane group compared with the reference group (p=0.047). Patients in the Mydrane group reported statistically greater comfort than the reference group before IOL insertion (p=0.034). Safety data were similar between groups. CONCLUSIONS: Mydrane is an effective and safe alternative to standard eye drops for initiating and maintaining intraoperative mydriasis and analgesia. Patients who received IC Mydrane were significantly more comfortable before IOL insertion than the reference group. Surgeons found IOL insertion less technically challenging with IC Mydrane. TRIAL REGISTRATION NUMBER: NCT02101359; Results.

A 3-day regimen with azithromycin 1.5% eyedrops for the treatment of purulent bacterial conjunctivitis in children: efficacy on clinical signs and impact on the burden of illness.

PURPOSE: To compare the efficacy of azithromycin 1.5% versus tobramycin 0.3% eyedrops on clinical ocular signs and symptoms of bacterial conjunctivitis in children and to assess the parents' satisfaction regarding the dosing regimen. PATIENTS AND METHODS: An international, multicenter, randomized, investigator-masked, controlled clinical trial conducted in children (1 day to 18 years old) with bulbar conjunctival hyperemia and purulent discharge. Azithromycin 1.5% was administered as 1 drop twice daily for 3 days, and tobramycin 0.3% as 1 drop every 2 hours for 2 days, then 4 times daily for 5 days. RESULTS: A total of 286 patients (mean age: 3.2 years) were enrolled. In children with bacteriologically positive cultures (N=203), azithromycin produced a significantly greater improvement in conjunctival discharge (P<0.01) and a trend (P=0.054) toward improvement in conjunctival hyperemia at day 7 than did tobramycin. Complete resolution of conjunctival discharge was significantly more frequent at day 3 on azithromycin than tobramycin (P=0.005). More parents found azithromycin easier to use (in terms of treatment duration, total number of instillations, instilling drops during the day, and difficulty in performing daily activities) than tobramycin. CONCLUSION: The azithromycin 1.5% regimen produced a rapid resolution of cardinal signs of purulent bacterial conjunctivitis with a more convenient dosage regimen. Such improved convenience is likely to improve compliance and lessen the burden of illness for patients and carers.

Efficacy and safety of azithromycin 1.5% eye drops in paediatric population with purulent bacterial conjunctivitis.

OBJECTIVE: To determine the efficacy and safety of azithromycin 1.5% eye drops in a paediatric population with purulent bacterial conjunctivitis. PATIENTS AND METHODS: This was a multicentre, international, randomised, investigator-masked study in 286 children with purulent discharge and bulbar conjunctival injection. Patients received either azithromycin 1.5% eye drops (twice daily for 3 days) or tobramycin 0.3% eye drops (every 2 h for 2 days, then four times daily for 5 days). Clinical signs were evaluated on day (D) 0, 3 and 7, and cultures on D0 and D7. The primary variable was the clinical cure (absence of bulbar conjunctival injection and discharge) on D3 in the worse eye for patients with positive cultures on D0. RESULTS: 286 patients (mean age 3.2 years; range 1 day-17 years) were included; 203 had positive cultures on D0. Azithromycin was superior to tobramycin in clinical cure rate on D3 (47.1% vs 28.7%, p=0.013) and was non-inferior to tobramycin on D7 (89.2% vs 78.2%, respectively). Azithromycin treatment eradicated causative pathogens, including resistant species, with a similar resolution rate to tobramycin (89.8% vs 87.2%, respectively). These results were confirmed in a subgroup of patients younger than 24 months old. CONCLUSIONS: Azithromycin 1.5% eye drops provided a more rapid clinical cure than tobramycin 0.3% eye drops in the treatment of purulent bacterial conjunctivitis in children, with a more convenient twice-a-day dosing regimen.

Comparison of corneal thickness and biomechanical properties between North African and French patients.

PURPOSE: To determine whether corneal thickness and rigidity vary between French and North African refractive surgery candidates. SETTING: Three clinics in North Africa and 1 hospital in France. DESIGN: Cross-sectional study. METHODS: In part 1, the central corneal thickness (CCT) in North African patients and French patients having preoperative examinations was retrospectively compared. In part 2, the biomechanical properties of the corneas in the 2 groups were prospectively compared. Comparisons were performed using the Student t and chi-square tests and multivariate linear and logistic regression. RESULTS: The retrospective study comprised 1662 patients from North Africa and 221 patients from France and the prospective study, 249 and 110, respectively. After adjustment for sex, age, and steepest keratometry, the mean CCT was statistically significantly thinner in North African patients (P<.0001). More than one fourth of North African patients had corneas thinner than 500 µm (28.9% versus 7.7% of French patients). Of patients with thin corneas, the mean corneal resistance factor (CRF) was statistically significantly lower in North African patients (P<.0001); there was no significant difference in corneal hysteresis. This remained true after adjustment for CCT (CCT-adjusted difference in CRF between groups: -0.78; range -1.27 to -0.28; P=.002). CONCLUSION: Corneas were thinner in North African patients than in French patients, and the CRF was different even when CCT was taken into accounted. More research is needed to determine whether these differences are associated with an additional risk for ectasia after laser in situ keratomileusis.