Name: intense pulsed light for the treatment of dry eye owing to meibomian gland dysfunction
Uploaded: 2019-04-01T13:00:00.000+00:00
Duration: 5 min
Description: Watch this Scientific Journal Video about Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction at JoVE.com

The authors have no acknowledgements to declare.

All participants were provided both verbal and written informed consent before any study procedure. The protocol of the study was carried out in accordance with the Declaration of Helsinki and was approved by the local Institutional Review Board.
1. Automated Ocular Surface Workup
<ol>
	<li>Noninvasive break-up time (BUT) and lipid layer thickness (LLT) evaluation
	<ol>
		<li>&#34;Install the &#34;I.C.P.&#34; program by SBM Sistemi on the computer connected to the device.</li>
		<li>Apply the device on&#160;the slip lamp.</li>
		<li>Open the application and insert the patient&#8217;s data.</li>
		<li>Select the exam to be performed in the menu: select NIBUT to measure the noninvasive BUT or Interferometry to evaluate the lipid layer type and thickness grade.</li>
		<li>Instruct the patient to put the chin and forehead in the correct position on the slit lamp with the device, and place the camera of the device in front of patient&#8217;s eye at a correct distance (about 1-2 cm).</li>
		<li>Ask the patient to blink twice, and then stare without blinking for as long as possible.</li>
		<li>Keep the instrument still and click the proper button to acquire the video. The system will provide the value of noninvasive BUT (time in s) or LLT (grade from 1 to 7). 
		Note: These exams are completely noninvasive, and it is not necessary to use any topical anesthetic or vital staining for the acquisitions and measurements.</li>
		<li>Repeat the same procedure for the other eye, if required.</li>
	</ol>
	</li>
	<li>Meibomian gland loss (MGL) assessment
	<ol>
		<li>Install the &#8220;I.C.P.&#8221; program by SBM Sistemi on the computer connected to the device.</li>
		<li>Open the program&#160;and insert patient&#8217;s data.</li>
		<li>Select Meibomian gland in the menu of the exams.</li>
		<li>Apply the device on the slip lamp.</li>
		<li>Gently evert the lower eyelid using a cotton swab.</li>
		<li>Acquire an infrared image of the inner part of the lower eyelid in order to obtain a good quality image of the meibomian glands, which appear whitish.</li>
		<li>Draw the margins of the lower eyelid area&#160;on the touchscreen and click to fill the area. 
		Note: The system automatically calculates the percentage of meibomian gland area in relation the total area of the eyelid. In addition, it is possible to use ImageJ software (National Institute of Health; http://imagej.nih.gov/ij) to analyze the images, and measure the MGL value as the percentage of gland loss in relation to the total tarsal area of the eyelid, as previously described16.</li>
		<li>Repeat the same procedure for the other eye, if required.</li>
	</ol>
	</li>
	<li>Tear osmolarity measurement
	<ol>
		<li>Clip the single use test card with a microchip into the top of the pen. The pen confirms when the test card is correctly attached.</li>
		<li>Gently move down the lateral lower eyelid using a cotton swab to create a little space between the eyeball and the eyelid.</li>
		<li>Place the tip of the test card in this space to collect a sample of tear fluid (50 nL) from the inferior lateral meniscus of the tear film. The pen confirms when the tear fluid sample has been properly collected. 
		Note: It is recommended to collect tear fluid at the outermost area of the eyelid to minimize the risk of corneal injuries.</li>
		<li>Dock the pen in the reader unit. The system reader measures and displays on the screen the osmolarity of the tear in m&#937;/L.</li>
		<li>Repeat the same procedure for the other eye, if required. 
		Note: Separate test cards are needed for each eye.</li>
	</ol>
	</li>
	<li>Subjective symptoms assessment
	<ol>
		<li>Administer the Ocular Surface Disease Index (OSDI) questionnaire.</li>
		<li>Ask the patient the 12 questions of the OSDI questionnaire, and circle the number in the box that best represents each answer. 
		Note: The patient needs to answer 12 questions and give a score from 0 to 4 to each answer.</li>
		<li>Calculate the sum of the scores of each question, and the total number of questions answered.</li>
		<li>Assess the severity of patient&#8217;s ocular discomfort symptoms using the specific chart.</li>
	</ol>
	</li>
	<li>Fitzpatrick skin phototype assessment
	<ol>
		<li>Determine the patient&#8217;s Fitzpatrick skin phototype score basing on the color of the patient&#8217;s skin and its reaction to sun exposure, as previously described by Fitzpatrick17. 
		Note: Patient&#8217;s Fitzpatrick skin phototype score is necessary to determine the proper treatment parameters for each patient.</li>
	</ol>
	</li>
</ol>
2. Intense Pulsed Light (IPL) treatment
<ol>
	<li>Seat the patient comfortably in a treatment chair or lying down on a couch in office.</li>
	<li>Press the start button on the LCD touchscreen of the control unit to activate the device.</li>
	<li>Select the treatment for MGD by pressing the proper button on the LCD touchscreen.</li>
	<li>Select the desired treatment energy level using the up and down arrows on the LCD touchscreen and then press on the Tick button to confirm the choice. Six different energy levels can be chosen, ranging from 9 J/cm2 to 13 J/cm2. 
	Note: Treatment energy level is determined basing on the Fitzpatrick skin phototype grading scale from I to V (grade VI is not suitable for IPL treatment). Darker skins need lower energy levels.</li>
	<li>Validate each of the six safety features by pressing the six icon-buttons one by one and then press the Tick button to confirm that the procedure is performed in total safety. 
	Note: A summary with all the selections made will be displayed on the LCD touchscreen.</li>
	<li>Press the Tick button to start the device and wait a few seconds until the device is ready for the treatment.</li>
	<li>Put the eyewear or the eye mask on the patient&#8217;s eyes in order to protect eyes from the emitted therapeutic lights.</li>
	<li>Wear safety glasses to protect the eyes from the emitted light (200-1400 nm).</li>
	<li>Apply a thick layer of optical gel over the skin under the lower eyelid, from the edge of the nose up to the temple, in order to conduct the light and help to spread the energy homogeneously. 
	Note: The gel layer should be at least 1 cm thick.</li>
	<li>Take the device handpiece from the central unit and gently push its head in direct contact with the skin of the area to be treated.</li>
	<li>Press the Start button over the handpiece to emit a single treating IPL pulse.</li>
	<li>Apply 5 single IPL pulses distributed along the area, starting from the inner canthus and progressing to the temporal area, trying to be as close as possible to the lower eyelid margin in order to obtain the greatest effect. (Figure 1) 
	Note: The upper eyelids are not treated directly because of the risk of light penetration through the eyelid with possible light absorption and subsequent structural damage and inflammation of the intraocular pigmented structures (i.e., iris tissue, ciliary body, uveal tissues).</li>
	<li>Remove gently the optical gel from the treated skin area.</li>
	<li>Place a warm compress over the eyelids of both eyes for 2-3 min.</li>
	<li>Repeat the same procedure for the other eye, if required. 
	Note: The total time session lasts only few minutes (about 10 min). Based on the physician&#8217;s choice, the meibomian gland of the lower eyelid of both eyes could be manually expressed after IPL treatment using expressor forceps or two cotton swabs.</li>
</ol>
3. Post-treatment Therapy
<ol>
	<li>Prescribe topical steroid eye drops 2 times per day for the following 10 days after the first session of IPL. 
	Note: Patients are encouraged to continue warm compresses and topical lubricants use at least twice daily during the treatment period.</li>
	<li>Repeat IPL treatment after 15 and 45 days to complete the starting treatment protocol. 
	Note: The standard protocol consists of 3 sessions at day 0, day 15 and day 45. Another additional optional session could be performed at day 75, based on the physician and the patient&#8217;s preferences. Repeated treatments could be necessary at regular follow-up to maintain the efficacy after the 3 initial sessions (loading-phase), depending on the single clinical case.</li>
</ol>
4. Post-treatment Assessment
<ol>
	<li>Examine carefully the patient&#8217; eyes and eyelids at the slit lamp.</li>
	<li>Repeat noninvasive BUT, LLT, meibography and tear osmolarity to evaluate the treatment efficacy.</li>
	<li>Administer the OSDI questionnaire to the patient to evaluate the patient&#8217;s symptoms.</li>
	<li>Ask the patient whether he perceived improvements from his baseline ocular discomfort symptoms according to a 5-grade scale: none = 0, trace = 1, mild = 2, moderate = 3, high = 4. 
	Note: It is recommended to wait at least 15 days after the third session before evaluating the clinical results obtained with the procedure.</li>
</ol>

<ol>
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The authors have nothing to disclose.

Intense pulsed light devices employ xenon gas-filled flash lamps to produce non-laser high intensity pulses of polychromatic non-coherent lights in a broad wavelength spectrum, from visible (515 nm) to infrared (1200 nm)18. The light energy pulse is released by the head of the handpiece by means of a sapphire or quartz block, and so directly applied onto the skin surface.
The mechanism of action of IPL systems is based on the principle of selective thermolisis, according to which certain targets, called chromophores, are capable of absorbing and then convert the light into heat energy12.
The particular characteristics of IPL devices make them capable of the simultaneous emission of different wavelengths lights (green, yellow, red and infrared), which allow to target at the same time the two main chromophores present in human skin, namely hemoglobin and melanin14,18.
Intense pulsed light treatment has been utilized for years in the field of dermatology, and recently, its use was translated to ophthalmology for the treatment of MGD, as a result of the improvement of dry eye symptoms in patients who underwent IPL treatment for facial rosacea19.
We describe the use and the therapeutic effects of a recently commercialized IPL device that was developed specifically for the treatment of MGD. In this device, IPL emission have been &#34;regulated&#34; in a multiple polychromatic train of calibrated and homogenously sequenced pulses.
To date, previous studies reported some improvements in terms of lid margin features (e.g., lid thickening and vascularity, telangiectasias, the number of plugged glands) and the secretion quality and expressibility of the meibomian glands after IPL treatment20,21,22,23,24. However, these measures are subjective, and prone to observer bias due to a low degree of standardization. Conversely, in order to overcome these drawbacks and improve the objectivity of the data, we used an automated quantitative analysis of ocular surface to evaluate the dry eye disease course after IPL treatment 25,26.
In our patients, noninvasive BUT significantly increased after IPL treatment, as previously reported by other research groups11,20,21,22,23,27, as a result of an improvement of tear film stability and a reduction in the tear evaporation rate. In addition, we found a significant increase of the tear film characteristics and the quality measured by LLT, in agreement with Craig, et al.27.
No significant changes were found for the tear osmolarity after IPL treatment, in agreement with other studies21,23,27. Although the recent TFOS DEWS II identified evaporation-induced tear hyperosmolarity as the core mechanism of dry eye disease8, MGD alone, without other ocular surface abnormalities, perhaps may not be sufficient to alter this parameter, particularly in milder or early stages of the disease. In fact, it should be highlighted that in our study, as well as in other MGD populations, tear osmolarity values were within the normal range21,26,28,29. Furthermore, the area of MGL did not change after IPL treatment in our patients. Conversely, the only previous study, which evaluated this parameter by noncontact infrared meibography, reported a 5% decrease of MGL after IPL treatment, suggesting a possible effect of this therapy upon meibomian gland parenchima30.
We investigated the patients&#39; subjective ocular discomfort by administering the OSDI questionnaire and a five-grade scale specifically focused on the patients&#39; perceived improvement in symptoms after the treatment. Despite the lack of a significant decrease of OSDI score after IPL, the vast majority of patients reported an overall improvement of ocular discomfort symptoms, and in about one third of the patients, this improvement was classified as moderate or high. These findings are in agreement with previous studies, which employed both validated questionnaires21,22,23,24,27,31 and specific scales of satisfaction11,20.
A careful patient selection is extremely important to obtain the best results from IPL. In fact, the treatment selectively acts on meibomian glands, whose dysfunction is the cause of evaporative DED, the most common subtype of dry eye. However, since DED is a multifactorial condition, the therapeutic approach should be dynamic, aiming at treating the dominating mechanism during the natural course of the disease. Therefore, IPL could be taken into consideration also in mixed forms of dry eye but in combination with other therapeutic options available.
IPL treatment provides an improvement of ocular surface parameters and discomfort symptoms. Regular repeated treatments may be required after the 3 starting sessions to maintain the beneficial effects of the procedure over the time. However, there is still no consensus about the time interval among treatments, which conversely should be customized according to the patient&#39;s satisfaction and changes of objective parameters.
The major limitation of the present study is represented by the lack of a control group. Additionally, the relatively small size of population might hamper the detection of further significance in case of small differences among parameters.
In conclusion, IPL for the treatment of patients with dry eye owing to meibomian gland dysfunction improved noninvasive break-up time and lipid layer thickness, as well as subjective symptoms.

Dry eye disease (DED) is an increasingly common condition and one of the most common reasons for clinical visits to an eye doctor1. The main symptom complained by patients affected by DED differs from various grades of redness and ocular discomfort to a chronic foreign body sensation, stinging, burning, itching, excessive tearing, pain, recurrent infections and transient visual disturbances2. The impact of DED on patients&#39; quality of life has been compared to that caused by moderate to severe angina or dialysis treatment3, and is associated with a restriction in daily activities and a loss of work productivity4.The recent definition of dry eye disease formulated by the TFOS DEWS II highlights its multifactorial nature, since different complex and heterogeneous alterations play a significant role in the onset and the maintenance of the disease2.
The vast majority of dry eye is caused by the so-called &#34;evaporative&#34; subtype that is mainly caused by meibomian gland dysfunction (MGD), a condition that affects up to 70% of the population in particular regions of the world5. Meibomian gland dysfunction is caused by a chronic alteration of the meibomian glands that are located inside the upper and lower eyelids. The disease is characterized by hyperkeratinization of the external duct of the glands and the obstruction of the orifices with insufficient, not functional, production of the external lipid layer of the tear film, resulting in tear instability6,7,8.
Currently, several different therapeutic strategies are available aiming at interrupting the vicious spiral of dry eye, and consist mainly of antibiotics, anti-inflammatory drugs, eyelid hygiene, warm compresses and tear substitutes9. However, these therapies are chronic and provide often only partial or short-term relief of symptoms, with subsequent compliance issues. Therefore, novel treatments with high efficacy and tolerability are desirable. In recent years, intense pulsed light (IPL) therapy has been widely used in dermatology for the treatment of different skin diseases such as acne, rosacea, telangiectasias and vascular and pigmented lesion (e.g., hemangiomas, venous malformations, port-wine stains)10. When the light is applied to the skin, it is absorbed by pigmented structures, such as blood cells and teleangectasias, with subsequent heat production that coagulates and destroys the abnormal blood vessels11. Recently, this technique was applied to the ophthalmic field for the treatment of DED owing to MGD. Several mechanisms have been postulated to explain the therapeutic effect of the procedure. Firstly, IPL treatment acts inducing thermal coagulation and selective ablation of superficial blood vessels and telangiectasias of the eyelids skin. Furthermore, the procedure reduces the release of inflammatory mediators and the levels of tear cytokines, which may promote the keratinization of mebomian glands terminal duct12,13. Secondly, the light energy transformed into heat causes the warming and liquefying of meibomian glands secretions, with subsequent melting and improved outflow11,14. More recently, other mechanisms such as the enhancement in collagen synthesis and connective tissue remodeling, the reduction in skin epithelial cell turnover, and the modulation of cellular inflammatory markers have also been hypothesized15.
In this study, we describe the use and the therapeutic effects of a recently commercialized IPL device, developed specifically for the treatment of MGD, in which IPL emission has been &#34;regulated&#34; in a multiple polychromatic train of calibrated and homogenously sequenced pulses. Therefore, the aim of this study is to describe the treatment procedure in detail, in order to spread it to the scientific medical community, giving the opportunity to ophthalmologists to expand their current armamentarium for the treatment of MGD.

<table><tbody><tr><td>I.C.P. Tearscope</td><td>SBM Sistemi, Turin, Italy</td><td>1340864/R</td><td>Device for noninvasvive break-up time and lipid layer thickness evaluation</td></tr><tr><td>I.C.P. MGD</td><td>SBM Sistemi, Turin, Italy</td><td>15006</td><td>Device performing infrared meibomography and meibomian gland loss evaluation</td></tr><tr><td>TearLab Osmolarity System</td><td>TearLab Corporation, San Diego, CA, USA</td><td>83861QW</td><td>Device for the measurement of tear osmolarity&amp;nbsp;</td></tr><tr><td>E&gt;Eye</td><td>E-Swin, Paris, France</td><td></td><td>Intense pulsed regulated light treatment device</td></tr><tr><td>BM 900 Slit Lamp Biomioscropy</td><td>Haag-Streit, Koeniz, Switzerland</td><td>BM 900</td><td>Slit Lamp Biomiscroscopy</td></tr><tr><td>Tobradex eye drops</td><td>Alcon Inc., Fort Worth, TX, USA</td><td>S01CA01</td><td>Eye drops instilled immediately after the procedure in office</td></tr></tbody></table>

intense pulsed light for the treatment of dry eye owing to meibomian gland dysfunction

Dry eye disease (DED) is an increasingly common condition and one of the most common complaints of patients. The vast majority of DED is caused by the so-called &#34;evaporative&#34; subtype, that is mainly caused by meibomian gland dysfunction (MGD). Intense pulsed light (IPL) devices employ high intensity pulses of polychromatic lights with a broad range of wavelength (515-1200 nm). IPL treatment has been utilized for years in the field of dermatology, and then its use was applied to ophthalmology for the treatment of MGD. Recently, a new device employing IPL was specifically designed for the periocular application. This procedure determines the thermal selective coagulation and ablation of superficial blood vessels and telangiectasias of the eyelids skin, reducing the release of inflammatory mediators and tear cytokines levels, and improving meibomian glands outflow. IPL treatment is noninvasive and easy to perform, lasts for only a few minutes and can be conducted in an office setting. In the present study, 19 patients underwent 3 sessions of IPL treatment. After treatment, both mean noninvasive break-up time and lipid layer thickness grade significantly increased, as a result of an improvement of tear film stability and quality, respectively. Conversely, no statistically significant changes were found for meibomian gland loss and tear osmolarity. Furthermore, the vast majority of the treated patients (17/19; 89.5% of the total) perceived an improvement of their ocular discomfort symptoms after IPL treatment. Although IPL treatment provides an improvement of both ocular surface parameters and ocular discomfort symptoms after one cycle of three sessions, regular repeated treatments are usually required to maintain the persistence over the time of its beneficial effects.

Nineteen patients (7 males and 12 females, mean age 39.3 &#177; 7.0 years) (mean &#177; standard deviation) underwent IPL treatment between September 2016 and June 2017. Fifteen days after the third IPL treatment session, noninvasive BUT significantly increased from 7.6 &#177; 0.6 s to 9.8 &#177; 0.7 s (mean &#177; standard error of the mean) (p = 0.017), and LLT grade significantly improved from 2.3 &#177; 0.1 to 3.4 &#177; 0.3 (p = 0.003). No statistically significant changes were found for MGL and tear osmolarity (23.9 &#177; 3.6% vs 25.4 &#177; 2.6% and 304.5 &#177; 2.4 m&#937;/L vs 300.6 &#177; 2.4 m&#937;/L, respectively; always p&#62;0.05) (Figure 2). In addition, mean OSDI score did not differ significantly before and after the last treatment session (p&#62;0.05).
Seventeen patients (89.5% of the total) showed an improvement of ocular discomfort symptoms after the treatment (mean grade 2.0 &#177; 1.2 out of 4). Figure 3 shows the distribution of patients&#39; perceived improvement in symptoms according to the 5-grade scale. The perceived improvement in symptoms was significantly correlated with the improvement of LLT after the treatment (r = 0.476, p = 0.039).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57811/57811fig1.jpg" /> 
Figure 1. Treatment area. The treatment area includes the lower eyelid, from the inner to the lateral canthus, the cheekbone and the temporal zone. Each red rectangle schematically represents the site of a single IPL pulse application. The numbers indicate the sequence of IPL pulse applications. <a href="https://www.jove.com/files/ftp_upload/59828/59828fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57811/57811fig2.jpg" /> 
Figure 2. Automated ocular surface workup before and after the treatment. Noninvasive BUT, lipid layer thickness (LLT), meibomian gland loss (MGL) and tear osmolarity before and 15 days after the third intense pulsed light treatment session. Error bars represent the standard error of the mean. <a href="https://www.jove.com/files/ftp_upload/59828/59828fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57811/57811fig3.jpg" /> 
Figure 3. Patients&#39; perceived improvement in dry eye symptoms after the treatment. The distribution of the patients according to the 5-grade scale about their perceived improvement in symptoms assessed 15 days after the third intense pulsed light treatment session. <a href="https://www.jove.com/files/ftp_upload/59828/59828fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction at JoVE.com

Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction

Dry eye disease is an increasingly common condition, which strongly impair patients&#39; life quality. Recently, a new device employing intense pulsed light, specifically designed for the periocular area, has been shown to improve tear film stability and ocular discomfort symptoms in dry eye disease owing to meibomian gland dysfunction.

Dry eye disease (DED) is an increasingly common condition and one of the most common complaints of patients. The vast majority of DED is caused by the ...

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Nanyang Technological University

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14.8K Views.  Carones Ophthalmology Center. Dry eye disease is an increasingly common condition, which strongly impair patients' life quality. Recently, a new device employing intense pulsed light, specifically designed for the periocular area, has been shown to improve tear film stability and ocular discomfort symptoms in dry eye disease owing to meibomian gland dysfunction.

Video: Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction

Induction of Ocular Surface Inflammation and Collection of Involved Tissues

Ocular surface diseases include a range of disorders that disturb the functions and structures of the cornea, conjunctiva, and the associated ocular surface gland network. Meibomian glands (MG) secrete lipids that create a covering layer that prevents the evaporation of the aqueous part of the tear film. Neutrophils and extracellular DNA traps populate MG and the ocular surface in a mouse model of allergic eye disease. Aggregated neutrophil extracellular traps (aggNETs) formulate a mesh-like matrix composed of extracellular chromatin that occludes MG outlets and conditions MG dysfunction. Here, a method for inducing ocular surface inflammation and MG dysfunction is presented. The procedures for collecting organs related to the ocular surface, such as the cornea, conjunctiva, and eyelids, are described in detail. Using established techniques for processing each organ, the major morphological and histopathological features of MG dysfunction are also shown. Ocular exudates offer the opportunity to assess the inflammatory state of the ocular surface. These procedures enable the investigation of topical and systemic anti-inflammatory interventions at the preclinical level.

Ocular surface inflammation harms the ocular surface tissues and compromises vital functions of the eye. The present protocol describes a method to induce ocular inflammation and collect compromised tissues in a mouse model of Meibomian gland dysfunction (MGD).

Ocular surface diseases include a range of disorders that disturb the functions and structures of the cornea, conjunctiva, and the associated ocular ...

Immunology and Infection

A Rabbit Model of Aqueous-Deficient Dry Eye Disease Induced by Concanavalin A Injection into the Lacrimal Glands: Application to Drug Efficacy Studies

Dry eye disease (DED), a multifactorial inflammatory disease of the ocular surface, affects 1 in 6 humans worldwide with staggering implications for quality of life and health care costs. The lack of informative animal models that recapitulate its key features impedes the search for new therapeutic agents for DED. Available DED animal models have limited reproducibility and efficacy. A model is presented here in which DED is induced by injecting the mitogen concanavalin A (Con A) into the orbital lacrimal glands of rabbits. Innovative aspects of this model are the use of ultrasound (US) guidance to ensure optimal and reproducible injection of Con A into the inferior lacrimal gland; injection of Con A into all orbital lacrimal glands that limits compensatory production of tears; and use of periodic repeat injections of Con A that prolong the state of DED at will. DED and its response to test agents are monitored with a panel of parameters that assess tear production, the stability of the tear film, and the status of the corneal and conjunctival mucosa. They include tear osmolarity, tear break-up time, Schirmer&#39;s tear test, rose bengal staining, and tear lactoferrin levels. The induction of DED and the monitoring of its parameters are described in detail. This model is simple, robust, reproducible, and informative. This animal model is suitable for the study of tear physiology and of the pathophysiology of DED as well as for the assessment of the efficacy and safety of candidate agents for the treatment of DED.

This article describes the development of a method to induce acute or chronic dry eye disease in rabbits by injecting concanavalin A to all portions of the orbital lacrimal gland system. This method, superior to those already reported, generates a reproducible, stable model of dry eye suitable for the study of pharmacological agents.

Dry eye disease (DED), a multifactorial inflammatory disease of the ocular surface, affects 1 in 6 humans worldwide with staggering implications for ...

Establishment of a Severe Dry Eye Model Using Complete Dacryoadenectomy in Rabbits

Dry eye disease (DED) is a complex disease with multiple etiologies and variable symptoms, having ocular surface inflammation as its key pathophysiologic step. Despite advances in our understanding of DED, significant knowledge gaps remain. Advances are limited in part due to the lack of informative animal models. The authors recently reported on a method of DED induced by injecting all orbital lacrimal gland (LG) tissues with the lectin concanavalin A. Here, we report a novel model of aqueous-deficient DED based on the surgical resection of all orbital LG (dacryoadenectomy) tissues. Both methods use rabbits because of their similarity to human eyes in terms of the size and structure of the ocular surface. One week after removal of the nictitating membrane, the orbital superior LG was surgically removed under anesthesia, followed by removal of the palpebral superior LG, and finally removal of the inferior LG. Dacryoadenectomy induced severe DED, evidenced by a marked reduction in the tear break up time test and the Schirmer&#39;s tear test, and significantly increased tear osmolarity and rose bengal staining. Dacryoadenectomy-induced DED lasted at least eight weeks. There were no complications and animals tolerated the procedure well. The technique can be mastered relatively easily by those with adequate surgical experience and appreciation of the relevant rabbit anatomy. Since this model recapitulates the features of human aqueous-deficient DED, it is suitable for studies of ocular surface homeostasis, DED, and candidate therapeutics.

A novel approach is presented to induce chronic dry eye disease in rabbits by surgically removing all orbital lacrimal glands. This method, distinct from those previously reported, produces a stable, reproducible model of aqueous deficient dry eye well suited to study tear physiology and pathophysiology and ocular therapeutics.

Dry eye disease (DED) is a complex disease with multiple etiologies and variable symptoms, having ocular surface inflammation as its key pathophysiologic ...

Effect of Artificial Tear Formulations on the Metabolic Activity of Human Corneal Epithelial Cells after Exposure to Desiccation

Artificial lipid-containing tear formulations are developed to reduce tear evaporation by the restoration of a deficient tear lipid layer. Artificial tear formulations that prevent cell desiccation will result in ocular surface protection and the maintenance of cell metabolic activity. During dehydration, cells undergo the process of loss of metabolic activity and subsequently cell death. This work describes a method for assessing the efficacy of artificial tear formulations. The metabolic dye (i.e., alamarBlue) changes from a low fluorescent molecule resazurin to a fluorescent molecule resorufin in viable cells. The biological performance of an artificial tear formulation is measured as the ability of the formulation to (a) maintain cell viability and (b) provide cell protection from desiccation. Growth media and saline are used as controls for the cell viability/desiccation tests. Cells are incubated with test solutions for 30 min and then desiccated for 0 or 5 min at 37 &#176;C and 45% relative humidity. Cell metabolic activity after initial exposure and after cell desiccation is then determined. The results show the comparative effects of eye drop formulations on cell metabolic activity and desiccation protection. This method can be used to test dry eye formulations that are designed to treat individuals with evaporative dry eye.

The purpose of this protocol is to evaluate if different artificial tear formulations can protect human corneal epithelial cells from desiccation using an in vitro model. After exposure to artificial tear formulations and desiccation, human corneal epithelial cells are assessed for metabolic activity.

Artificial lipid-containing tear formulations are developed to reduce tear evaporation by the restoration of a deficient tear lipid layer. Artificial tear ...

Platelet-Rich Plasma Lysate for Treatment of Eye Surface Diseases

Various ocular surface diseases are treated with blood-derived eye drops. Their use has been introduced in clinical practice because of their metabolite and growth factor content, which promotes eye surface regeneration. Blood-based eye drops can be prepared from different sources (i.e., whole blood or platelet apheresis donation), as well as with different protocols (e.g., different dilutions and freeze/thaw cycles). This variability hampers the standardization of clinical protocols and, consequently, the evaluation of their clinical efficacy. Detailing and sharing the methodological procedures may contribute to defining common guidelines. Over the last years, allogenic products have been diffusing as an alternative to the autologous treatments since they guarantee higher efficacy standards; among them, the platelet-rich plasma lysate (PRP-L) eye drops are prepared with simple manufacturing procedures. In the transfusion medicine unit at AUSL-IRCCS di Reggio Emilia, Italy, PRP-L is obtained from platelet-apheresis donation. This product is initially diluted to 0.3 x 109 platelets/mL (starting from an average concentration of 1 x 109 platelets/mL) in 0.9% NaCl. Diluted platelets are frozen/thawed and, subsequently, centrifuged to eliminate debris. The final volume is split into 1.45 mL aliquots and stored at &#8722;80 &#176;C. Before being dispensed to patients, eye drops are tested for sterility. Patients may store platelet lysates at &#8722;15 &#176;C for up to 1 month. The growth factor composition is also assessed from randomly selected aliquots, and the mean values are reported here.

Platelet lysates represent an emerging tool for the treatment of ocular surface diseases. Here, we propose a method for the preparation, dispensation, storage, and characterization of platelet lysate collected from platelet donors.

Various ocular surface diseases are treated with blood-derived eye drops. Their use has been introduced in clinical practice because of their metabolite ...

Standardizing Press Needle Treatment for Myopia with Dry Eye

Press Needle: A Traditional Chinese Medicine Therapy for Myopia Patients with Dry Eye

Most patients with myopia have dry eye, which has been shown to adversely affect ocular symptoms, myopia progression, and quality of life in patients with myopia. Needle prickling has been shown to be effective in providing symptom relief in patients with myopia and dry eye. Press needle is a long-lasting, easy-to-operate, and inexpensive traditional Chinese medicine treatment. The standard practice of needle insertion is very important for the treatment of myopia and dry eye. The specific steps include selecting the appropriate acupoints, piercing them with appropriate needles, and fixing them in the skin or subcutaneously at the acupoints, burying them for 2 days, resting for 1 day; the course of treatment lasts for 2 weeks. Specifically, the following indicators were assessed: uncorrected visual acuity and the ocular surface disease index. This article will explain how to standardize the operation of a press needle in the treatment of myopia and dry eye.

Author Spotlight: Exploring Press Needle Efficacy and Underlying Molecular Pathways

Here, we present a protocol to standardize the operation of acupuncture in the treatment of myopia with dry eye.

Most patients with myopia have dry eye, which has been shown to adversely affect ocular symptoms, myopia progression, and quality of life in patients with ...

Establishment of A Mouse Model of Aqueous Deficiency Dry Eye

Dry eye disease is a prevalent condition affecting 5%-50% of the global population. Animal model investigations play a crucial role in understanding its underlying mechanisms. Therefore, we developed a mouse model of dry eye disease by surgically removing both the extraorbital lacrimal glands (ELG) and intraorbital lacrimal glands (ILG) to investigate the ocular surface pathology in the context of aqueous deficiency dry eye. Two weeks post operation, the mice exhibited severe dry eye manifestations, including reduced tear secretion, corneal epithelial irregularities, positive fluorescein sodium staining, and neovascularization. Histological examination via hematoxylin and eosin staining revealed inflammatory cell infiltration and corneal epithelium dysplasia. Immunofluorescence staining and quantitative reverse-transcription polymerase chain reaction revealed decreased expression of the normal corneal epithelial biomarkers K12 and Pax6 and increased expression of Sprr1b in the corneal epithelium. These ocular manifestations indicated abnormal corneal epithelial differentiation. Furthermore, immunofluorescence staining of Ki67 revealed the increasing cell proliferation. In conclusion, the ELG plus ILG excision model proved suitable for studying changes in the ocular surface and elucidating the mechanisms underlying aqueous deficiency dry eye.

Here, we present a method to establish a mouse model of aqueous-deficient dry eye by excising the extraorbital and infraorbital lacrimal glands and evaluate the changes in the ocular surface in aqueous deficiency dry eye.

Dry eye disease is a prevalent condition affecting 5%-50% of the global population. Animal model investigations play a crucial role in understanding its ...

Nasolacrimal Lavage as a Treatment for Ocular Surface Toxic Soup Syndrome

Ocular surface toxic soup syndrome (OSTSS) is characterized by inadequate tear drainage through the nasolacrimal duct system, leading to the accumulation of inflammatory mediators in the tear film. This condition can result in toxic keratoconjunctivitis, with symptoms such as conjunctival hyperemia, itchiness, discomfort, and epiphora. Dilation and irrigation are common diagnostic procedures in both optometry and ophthalmology, used to assess nasolacrimal duct obstruction in cases of epiphora. This technique involves the injection of saline into the nasolacrimal duct system through the puncta, followed by the evaluation of reflux, which indicates obstruction. Although intended to be diagnostic, many patients report significant improvements in epiphora and ocular comfort after the procedure. In this paper, we present a case study in which a patient achieved complete resolution of epiphora and itchiness following therapeutic nasolacrimal lavage performed every 2 months. Subjective improvements in symptoms in 3 additional patients are also reported. We propose nasolacrimal lavage not only as a diagnostic tool but also as an effective therapeutic intervention for managing OSTSS.

OSTSS leads to pooled inflammatory mediators in the tear film, causing symptoms like epiphora and discomfort. Here, we present a case where therapeutic nasolacrimal lavage every 2 months resolved epiphora and itchiness, suggesting its efficacy as a therapeutic intervention for OSTSS. Additionally, we report subjective improvements in symptoms in 3 additional patients.

Ocular surface toxic soup syndrome (OSTSS) is characterized by inadequate tear drainage through the nasolacrimal duct system, leading to the accumulation ...

A Method to Induce Ocular Surface Inflammation in a Murine Model

Source: Singh, J., et al. <a href="https://app.jove.com/v/63890">Induction of Ocular Surface Inflammation and Collection of Involved Tissues.</a> J. Vis. Exp. (2022)
This video demonstrates a method to induce ocular surface inflammation and meibomian gland dysfunction in a murine model. Stimulation of the mouse&#39;s immune system using an immunogen and later restimulation with the same immunogen promotes ocular surface inflammation, which causes plugging of meibomian gland secretion through neutrophil-produced aggNETs and leads to dry eye disease.

Source: Singh, J., et al. Induction of Ocular Surface Inflammation and Collection of Involved Tissues. J. Vis. Exp. (2022)
This video demonstrates a ...

JoVE Encyclopedia of Experiments

Immunology

Immune Response

Immune Modulation

Performing Injection into Orbital Lobe of Superior Lacrimal Gland: A Technique for Inducing Dry Eye Disease in Rabbit Model

Apply medial pressure to the globe to cause the orbital superior lacrimal gland to protrude from the posterior incisure. Using closed curved forceps, indent the area until the bony opening in the skull is felt, and apply further modest pressure with forceps to leave an indentation in the skin to serve as the landmark for the needle placement.
Insert a tuberculin syringe equipped with a 27-gauge needle perpendicular to the skin over the indentation mark about a 1/4 inch into the incision, and redirect the needle posteriorly and externally toward the lateral canthus, aiming for the midpoint between the injection site and the bony orbital rim. Once the hub of the needle is reached, slowly inject 0.2 milliliters of a 1,000 microgram solution of conA.