Влияние применения склеральных линз на течение синдрома сухого глаза у пациентов с кератоконусом

Introduction. The literature data confirm a relationship between keratoconus (KC) and signs of dry eye syndrome (DES). The scleral rigid gas permeable contact lenses widely used in the optical correction of keratoconus are more often used in the treatment of dry eye syndrome to protect the cornea and tear film.Aim. To evaluate changes in the condition of the cornea and tear film in keratoconus associated with dry eye syndrome during the use of scleral rigid gas permeable contact lenses in combination with/without tear replacement therapy.Materials and methods. A total of 30 patients (60 eyes) with bilateral stabilized non-operated keratoconus at different stages associated with dry eye syndrome were examined. The patients were divided into groups: Group 1 included 15 patients (30 eyes), who used 0.9% sodium chloride (saline solution) as a moisturizing solution to fill the lens cup before it was placed in the eye; Group 2 included 15 patients (30 eyes) who used 0.18% sodium hyaluronate as a moisturizing solution. All patients underwent the following examinations: biomicroscopy of the anterior segment of the eye using a vital dye (0.1% fluorescein sodium) and assessment of the degrees of epitheliopathy of the conjunctiva and cornea according to the Oxford grading system, determination of the precorneal tear film break-up time (Norn test), as well as the status of total (Schirmer test) and basic (Jones test) tear production.Results and discussion. Wearing scleral rigid gas-permeable contact lenses, regardless of the type of solution filled into the lens cup before placing it in the eye, improves significantly the ocular surface condition and increases the results of function tests.Conclusion. The observed tendency towards a higher capacity to repair corneal tissues during the use of 0.18% sodium hyaluronate preservative-free tear replacement agent in the sublens space is confirmed by corneal confocal microscopy outcomes and indicates the greater efficacy of using a combination with a tear replacement agent.

Seeing through tears: Understanding and managing dry eye disease.

The central lower TMH is used as a clinical measure of tear volume in the assessment of contact lens candidates and patients with dry eyes. Ethnic differences in eyelid morphology may influence the measurement of the TMH. Furthermore, with the advent of larger contact lenses, such as scleral lenses, it would be of clinical value to assess the TMH centrally and peripherally. The purpose of this study was to evaluate and compare the TMH at different positions along the palpebral margin between Caucasian and Asian eyes. This prospective study evaluated the lower TMH in five positions (central, temporal and nasal limbus and temporal and nasal periphery) of the right eye using the Keratograph 5M (Oculus) instrument in Caucasian and Asian participants between 10 am and 12 pm . The TMH at each position was taken three times and averaged and analyzed using a 5 × 2 repeated-measures analysis of variance. Central TMH did not differ significantly ( F = 0.02, p=0.88) in Caucasians (n = 20, aged 24.45 [2.30] years, TMH 0.320 [0.052] mm) and Asians (n = 20, aged 22.25 [3.43] years, TMH 0.325 [0.048] mm). A difference was noted with respect to TMH positions along the lid margin ( F = 64.17, p<0.001), independent of ethnicity ( F = 2.15, p=0.15). A post hoc analysis revealed a significantly higher TMH temporally when compared with centrally or nasally (p<0.001). This study demonstrated the similarity of the central TMH and the differences in the peripheral TMH within Caucasian and Asian eyes. This may be clinically relevant when using the Tear Film & Ocular Surface Society Dry Eye Workshop II diagnostic algorithm for dry eyes and when fitting scleral contact lenses. Future studies need to consider that ethnic differences may exist for certain tests in order to personalize the care and management of each patient.

SummaryUse of blown glass shells, the precursors of scleral lenses, for management of keratoconus was first described in the late 1800's. Keratoconus has been a leading indication for scleral lenses throughout the history of the devices, both prior to and following the introduction of rigid gas permeable scleral lenses in 1983. Scleral lenses offer several benefits compared to corneal lenses for primary corneal ectasia. They do not require alignment with a highly irregular corneal surface, and are instead supported by the conjunctival tissue overlying the relatively regular sclera. They offer excellent comfort and lens stability. Scleral lenses do not touch the cornea, so may be less likely to lead to corneal epitheliopathy or scarring. Unlike corneal transplantation, scleral lenses can immediately provide improvement in the quality of vision, and are considerably less invasive. Furthermore, scleral lenses may provide improved ocular comfort for patients with concurrent keratoconus and atopic disease of the lids and adnexa. This presentation will review and summarize visual and ocular outcomes of scleral lens therapy for management of exposure keratopathy at the Mayo Clinic.

To evaluate the most important signs of dry eye, such as osmolarity, inflammation, and diadenosine tetraphosphate (Ap(4)A) concentration before and after wearing scleral lenses for 8 h in keratoconus patients. A pilot, experimental, short-term study involved 26 keratoconus patients (average age, 36.95 ± 8.95 years). They voluntarily enrolled in the study at the Optometry Clinic of the Faculty of Optics and Optometry in the University Complutense of Madrid. They were divided into two groups: patients with intrastromal corneal ring, the ICRS group, and patients without ICRS, the keratoconus (KC) group. Ocular Surface Disease Index questionnaire, the Schirmer test without anesthesia, tear break-up time, matrix metalloproteinase 9 (MMP-9) concentration, osmolarity, and Ap4A concentration were evaluated before and after wearing a scleral lens for 8 h. The patients wore the scleral lenses from 6 to 9 h, with a mean of 7.59 ± 0.73 h. The mean scleral lens sag for all patients was 4310 ± 166.31 μm, ranging from 4200 μm to 4800 μm. No significant changes in the Schirmer test and tear break-up time were found for either group. Ocular Surface Disease Index scores were statistically lower after wearing scleral lenses for both groups (p < 0.05). A significantly lower osmolarity and a significant rise of MMP-9 concentration after wearing scleral lenses were found in both groups (p < 0.05). Diadenosine tetraphosphate concentration was lower after wearing the scleral lens in the KC group (p < 0.05) but no significant difference was found for the ICRS group (p > 0.05). Short-term scleral lens wearing improves the symptomatology and some signs of dry eye, such as osmolarity and Ap4A concentration. The increase of MMP-9 concentration could be caused by tear film stagnation and use of preserved saline.

Dry eye disease (DED) represents a heterogeneous group of conditions with tear film insufficiency and signs and/or symptoms of ocular surface irritation. The clinical manifestations of DED can be highly variable; hence the diagnosis is often based on a combination of symptoms, signs, and clinical tests, given that any one of these alone would miss a significant number of patients. Similarly, the treatment must often be tailored to each patient by targeting the specific mechanisms involved in his or her disease. The purpose of this review is to summarize recent advances that have allowed us to better recognize, categorize, and treat patients with DED. The most notable new diagnostic tests in DED are tear film osmolarity, inflammatory biomarkers, and meibomian gland imaging. Therapeutically, anti-inflammatory therapy, meibomian gland heating and expression, and scleral contact lenses are some of the latest options available for treating DED.

PURPOSE: (1) To qualify complaints of quality of vision in patients with (severe) keratoconjunctivitis sicca by examining straylight values and (2) to check for an effect of scleral lens wear on straylight. METHODS: Straylight was measured in 16 patients with severe keratoconjunctivitis sicca using the Oculus C-Quant. In 9 of these patients, scleral lenses were used, and straylight was measured with and without scleral lenses. Other tests included the Schirmer test, visual acuity, the van Bijsterveld score, and a straylight questionnaire. RESULTS: Patients with keratoconjunctivitis sicca had a mean straylight OD of log(s) = 1.36 ± 0.19 SD and OS of log(s) = 1.45 ± 0.17 SD. Mean age was 56 ± 9.3 SD. This was significantly higher than the mean age-matched normal value of log(s) = 1.10 (P < 0.001). Such a straylight increase is functionally significant. The difference in straylight with and without scleral lenses was 0.06 log units ± 0.02 SD, but this was not statistically significant for OD (P = 0.134) and OS (P = 0.293). No correlation was found between straylight and the van Bijsterveld score on the corneal section for OD (P = 0.326) and OS (P = 0.433). CONCLUSIONS: Keratoconjunctivitis sicca leads to increased straylight. However, this increase was not correlated to the amount of surface damage graded with the van Bijsterveld score. Further study on the cornea is necessary to determine the source of the increased straylight. Scleral lenses do not have a noteworthy influence on straylight in these patients.

Tear film stability plays an important role in the quality of vision. We present an interferometric method for assessing the stability of precorneal tear film in real time. A lateral shearing technique is applied as a noninvasive and sensitive method for investigating tear film stability and the smoothness of the tear film surface by quantitative evaluation of the interference fringe pattern. The evaporation of tears and the appearance of tear film break-up between blinks cause changes in the fringe geometry. For quantitative assessment of the fringe smoothness and consequently of the tear film structure, the fast Fourier transform (FFT) is applied. Four parameters are used to quantitatively estimate dynamic changes in the tear film stability of the cornea 20 s after the eye blink. Examples of examined interferograms recorded in patients with healthy eyes, patients suffering from dry-eye syndrome, and patients wearing contact lenses are given. Significant differences between the stability of the tear film in the healthy eye and that in the dry eye and the eye with a contact lens are observed. The favorable influence of artificial tears applied in patients with dry-eye syndrome or contact lenses is also discussed.

Context: The study objective was to compare precorneal tear film in terms of amount and stability in diabetic individuals. Aims: The aim was to study the effect of diabetes on the amount and stability of precorneal tear film. Settings and Design: This is a hospital-based, prospective, case-controlled, observational study of 1-year duration. Sixty-five sequentially collected patients with diabetes attending the Ophthalmology outpatient department/inpatient department at AVBRH were selected for the study after taking the inclusion and exclusion criteria into consideration. Informed consent was obtained from all participants after approval by the Institutional Ethical Committee of the college. Subjects and Methods: After enrollment of the participants in the study, all underwent a thorough ophthalmic examination. Tear film break up time (TBUT) and Schirmer test without anesthesia followed by with anesthesia were calculated. Statistical Analysis Used: Statistical analysis was done using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test, SPSS 17.0 version and GraphPad 6.0 version software (Biomatters, Ltd. NZ and GSL Biotech, USA) were used in the analysis, and P &lt; 0.05 was considered the level of statistical significance (P &lt; 0.05). Results: Patients with diabetes showed unstable tear film. The amount of tear film measurement also decreases in diabetics. A higher number of positive test results for both Schirmer test and TBUT test were found in patients having a duration of diabetes &gt;5 years. Conclusions: Longer duration of diabetes is associated with dry eye. Diabetes is associated with a reduction in the amount of precorneal tear film as well as an unstable precorneal tear film.

To report a patient with chronic ocular graft versus host disease who achieved long-term stability of a descemetocele using prosthetic replacement of the ocular surface ecosystem (PROSE) treatment. Case report and literature review. A 60-year-old white man, who underwent PROSE treatment 4 years earlier to address severe dry eyes secondary to ocular graft versus host disease, developed a central corneal ulcer that resulted in descemetocele formation. Because of the risks of surgical intervention in an immunocompromised patient with severe ocular surface disease, the descemetocele was monitored closely as the patient continued PROSE device wear. After 1 year with continued PROSE therapy, the patient's descemetocele remained stable without perforation and corrected visual acuity stabilized at 20/50 in the affected eye. This is the first case that reports stabilization of a descemetocele with a PROSE device. For patients at high risk for postsurgical complications, PROSE treatment could be considered as an alternative to corneal transplantation and as an adjunct to other ocular therapies in patients with descemetocele formation.

Dry eye syndrome is a global problem of the modern world. Overload of information, rapid urbanization, and a busy lifestyle lead to non-compliance with work and rest schedules, including increased visual loads, decreased stress resistance in conditions of time deficit, leading to a deficiency of vital substances in the body. All the above are risk factors for the development of dry eye syndrome and affect the course of this disease. It is a well-known fact that balanced nutrition, regular intake of vitamins and microelements with food, and compliance with work and rest schedules play a role in the prevention and elimination of clinical manifestations of these conditions. This article presents the results of using the biologically active food supplement “DOPPELHERZ® V.I.P. OFTALMOVIT No. 30” (manufacturer Queisser Pharma GmbH &amp; Co. KG, Germany) in the treatment of dry eye syndrome. The purpose of the study: to evaluate the effect of the dietary supplement “DOPPELHERZ® V.I.P. OFTALMOVIT no. 30” in the treatment of dry eye syndrome. Material and methods. The study included 90 students with dry eye syndrome, aged 18 to 26 years. Patients of group I (control) did not receive any dietary supplements; group II (study group) received the dietary supplement “DOPPELHERZ® V.I.P. OFTALMOVIT”. Results. OSDI questionnaire — in the study group, the severity of dry eye syndrome: “before” moderate n = 38, severe n = 22, “1 month” moderate n = 43, severe n = 17, “2 months” mild n = 11, moderate n = 43, severe n = 6, in the control group no changes ( p = 0.368). Norn’s test: the study group showed an increase in tear film breakup time ( p &lt; 0.001), no changes were recorded in the control group ( p = 0.285). Lacrimal meniscus height: the study group showed an increase in the height of the lacrimal meniscus, which indicates an improvement in the functional properties of the tear film and a decrease in dry eye syndrome ( p &lt; 0.001), no changes were recorded in the control group ( p = 0.105). Schirmer tests 1 and 2: the study group showed an increase in the tear film breakup time, which indicates an improvement in the functional properties of the tear film and a decrease in dry eye syndrome, no changes were recorded in the control group (RSH1 = 0.587, RSH2 = 0.293). CISS questionnaire: a gradual decrease in the severity of asthenopia signs was observed in the study group ( p &lt; 0.001), no changes were recorded in the control group ( p = 0.125). Pupillography: in the study group, regression of accommodation tension was recorded, more pronounced after 2 months ( p &lt; 0.001), in the control group there was a change in accommodation tension, which can be associated with the alternating predominance of sympathetic and parasympathetic wagging ( p &lt; 0.05). Discussion. The concept of dry eye syndrome treatment includes etiopathogenetic, non-specific and symptomatic therapy. An integral link in the strategy of pathogenetic treatment of dry eye syndrome is the targeted introduction of vitamins and microelements into the diet. Conclusion. Based on the results of the study, as well as on the data of foreign and domestic authors, dietary supplements can serve as an additional source of vitamins and microelements, the deficiency of which is one of the components of the causes of dry eye syndrome pathogenesis. Considering the above, we can recommend taking the dietary supplement “DOPPELHERTS ® V.I.P. OFTALMOVIT” 1 capsule once a day for 2 months in the complex therapy of patients with dry eye syndrome.

To evaluate the indications for modern scleral lenses and their clinical performance in patients who were fitted with scleral lenses at the authors' practices. In this cross-sectional survey, all the necessary data were obtained at the first follow-up visit during the 5-month study period. There were four types of scleral lenses: spherical, front-surface toric, back-surface toric, and bitoric. The preformed scleral lens fitting technique developed at Visser Contact Lens Practice was used in all patients. The lenses were cut by precise Sub Micron Lathing from a Boston Equalens II blank at Procornea. Visual acuity and slitlamp findings were recorded. A specially designed classification for scleral lens fitting was used to investigate clinical performance. The largest proportion of the 178 patients (284 eyes) were diagnosed with keratoconus (143 [50.4%] eyes) followed by postpenetrating keratoplasty (56 [19.7%] eyes). The remaining diagnoses were irregular astigmatism, keratitis sicca, corneal dystrophy, and multiple diagnoses. The ratio of spherical to back-surface toric designs was 1:1.1. Clinical examination showed sharp increases in visual acuity (median increase, 0.45) and safe physiologic responses of the anterior eye. All the patients could continue to wear scleral lenses, with 79.2% with the same lens parameters. Several types of corneal abnormality were managed successfully with modern scleral lenses. The main indication was optical correction of an irregular corneal surface. Satisfactory clinical performance meant that all the patients could continue to wear their scleral lenses.

Corneal refractive surgeries are one of the commonly performed procedures for correction of refractive errors. Tear film abnormality is the most common postoperative complication of corneal refractive surgeries. Consequently, these procedures represent a clinically significant cause of dry eye disease. The mechanisms which lead to dry eye disease include corneal sensory nerve dysfunction, ocular surface desiccation, glandular apoptosis and ocular surface inflammation. Although transient tear film abnormalities occur in almost all patients following surgery, patients with pre-existing dry eye symptoms or dry eye disease are at significant risk of developing more severe or long-term ocular surface disease. As such, careful patient selection and preoperative evaluation is essential to ensuring successful surgical outcomes. This is particularly important with LASIK which has the strongest association with dry eye disease. Appropriate surface lubrication and anti-inflammatory therapy remains the cornerstone treatment. Timely and effective management is important to facilitate visual rehabilitation and reduce the risk of secondary complications. In this review we describe the causes, pathophysiology, risk factors, manifestations, and management of tear film dysfunction and dry eye disease following corneal refractive surgery.

Anatomical and physiological considerations in scleral lens wear: Eyelids and tear film

Background/Objectives: Dry eye (DE) can cause persistent eye rubbing, contributing to keratoconus (KC) development and progression. Both keratoconus (KC) and dry eye (DE) significantly impact patients’ functional and emotional well-being, with KC patients exhibiting a higher prevalence of DE symptoms and signs. This study examined whether functional (KEPAQ-F) and emotional (KEPAQ-E) quality of life, assessed by the Keratoconus End-Points Assessment Questionnaire, differ when influenced by symptoms and clinical signs of general DE versus meibomian gland dysfunction (MGD) in KC patients. Methods: Volunteers with KC (ages 18–70) underwent DE and MGD assessments, completing OSDI, MGD (MGDQ), and KEPAQ questionnaires. Clinical measures included NITBUT, Schirmer, and meibography. Pearson correlations and path analysis assessed relationships between DE and MGD symptoms and KEPAQ-F/E. Results: Forty-five KC participants (mean age: 45 ± 13, range: 20–69 years, 25 males) were enrolled; 22 (49%) had DE, and 15 (33%) had MGD. Significant correlations were observed between KEPAQ-E (2.9 ± 3.0 Logit) and KEPAQ-F (1.7 ± 3.0 Logit) scores with OSDI (26.5 ± 26.7) and MGDQ (3.3 ± 2.2) scores, and all Belin outcome measures A-D for all participants. In participants with diagnosed dry eye, KEPAQ E and F were also significantly correlated with loss of meibomian glands in the lower eyelids (R = −0.44, p = 0.04). Path analysis showed both DE and MGD were negatively correlated with lower KEPAQ-E and KEPAQ-F scores, with DE symptoms more influential (p < 0.05). The model explained 42% of the KEPAQ-E variance and 41% of the KEPAQ-F variance. Conclusions: Emotional and functional quality of life in KC is significantly and negatively related to DE and MGD symptoms, with DE symptoms exhibiting a greater impact. Furthermore, greater loss of meibomian glands in the lower eyelids is significantly associated with reduced emotional and functional KEPAQ scores in DE patients. These results underscore the critical importance of evaluating DE in KC to improve patient-reported outcomes.