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Medscape

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjogren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.

TFOS DEWS II pathophysiology report

The members of the Management and Therapy Subcommittee undertook an evidence-based review of current dry eye therapies and management options. Management options reviewed in detail included treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, surgical approaches, dietary modifications, environmental considerations and complementary therapies. Following this extensive review it became clear that many of the treatments available for the management of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due to a lack of appropriate masking, randomization or controls and in some cases due to issues with selection bias or inadequate sample size. Reflecting on all available evidence, a staged management algorithm was derived that presents a step-wise approach to implementing the various management and therapeutic options according to disease severity. While this exercise indicated that differentiating between aqueous-deficient and evaporative dry eye disease was critical in selecting the most appropriate management strategy, it also highlighted challenges, based on the limited evidence currently available, in predicting relative benefits of specific management options, in managing the two dry eye disease subtypes. Further evidence is required to support the introduction, and continued use, of many of the treatment options currently available to manage dry eye disease, as well as to inform appropriate treatment starting points and understand treatment specificity in relation to dry eye disease subtype.

TFOS DEWS II Management and Therapy Report

Corneal structure and transparency

The damaging effect of UV rays (with the wavelength shorter than 320 nm) on the rabbit anterior eye segment. I. Early changes and their prevention by catalase-aprotinin application

Reactive oxygen species (ROS) generated by xanthine oxidase in the corneal epithelium and thelr potential participation in the damage of the corneal epithelium after prolonged use of contact lenses in rabbits

Metabolic changes in rabbit cornea after combined long-term steroid treatment and UV-B exposure were investigated. Corneas were exposed to UV-B radiation (2.05 J/cm2) after 36 days topical pretreatment with either 0.1% dexamethasone or saline. Twenty-four hours after UV-B exposure, corneas were excised and aqueous humour aspirated. Intact corneal tissues were analyzed by magic angle spinning proton NMR spectroscopy and pattern recognition methods. UV-B decreased corneal ascorbate (63% reduction), taurine (62%), and choline (63%), whereas glucose was elevated. Dexamethasone pretreatment further depleted corneal taurine and ascorbate, decreased aqueous ascorbate (85%), and accumulated glucose in cornea and aqueous humour. The results reflect antioxidative mechanisms and osmoregulation.

High-Resolution MAS 1H NMR Spectroscopic Analysis of Rabbit Cornea After Treatment with Dexamethasone and Exposure to UV-B Radiation

The usefulness of enzyme histochemical methods for the localization of enzymes as catalysts of molecular interactions in the cells and tissues of healing corneal wounds is shown in rabbits. The current data on corneal wound healing in humans as well as in rabbits with particular reference to serine proteases are reviewed. Some inflammatory mediators are also discussed. Plasmin is a serine protease which is absent (or present only in very low concentration) in the tear fluid, and its activity appears under various pathological conditions in humans or following experimental injuries in rabbits. The role of increasing plasmin activity in the tear fluid in the depending upon the severity of corneal injury is evaluated. Great attention is devoted to conditions leading to long-lasting elevated levels of plasmin activity in the tear fluid correlated with corneal ulceration. The differences between the histochemical pattern of untreated corneas or corneas treated with some serine protease inhibitors are shown, and the efficacy of these drugs is discussed in light of present knowledge.

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Enzyme histochemistry of corneal wound healing

Xanthine oxidoreductase (xanthine dehydrogenase + xanthine oxidase) is a complex enzyme that catalyzes the oxidation of hypoxanthine to xanthine, subsequently producing uric acid. The enzyme complex exists in separate but interconvertible forms, xanthine dehydrogenase and xanthine oxidase, which generate reactive oxygen species (ROS), a well known causative factor in ischemia/reperfusion injury and also in some other pathological states and diseases. Because the enzymes had not been localized in human corneas until now, the aim of this study was to detect xanthine oxidoreductase and xanthine oxidase in the corneas of normal post-mortem human eyes using histochemical and immunohistochemical methods. Xanthine oxidoreductase activity was demonstrated by the tetrazolium salt reduction method and xanthine oxidase activity was detected by methods based on cerium ion capture of hydrogen peroxide. For immunohistochemical studies. we used rabbit antibovine xanthine oxidase antibody, rabbit antihuman xanthine oxidase antibody and monoclonal mouse antihuman xanthine oxidase/xanthine dehydrogenase/aldehyde oxidase antibody. The results show that the enzymes are present in the corneal epithelium and endothelium. The activity of xanthine oxidoreductase is higher than that of xanthine oxidase, as clearly seen in the epithelium. Further studies are necessary to elucidate the role of these enzymes in the diseased human cornea. Based on the findings obtained in this study (xanthine oxidoreductase/xanthine oxidase activities are present in normal human corneas), we hypothesize that during various pathological states, xanthine oxidase-generated ROS might be involved in oxidative eye injury.

Jitka Cejkova

Papers

The damaging effect of UV rays (with the wavelength shorter than 320 nm) on the rabbit anterior eye segment. I. Early changes and their prevention by catalase-aprotinin application

Reactive oxygen species (ROS) generated by xanthine oxidase in the corneal epithelium and thelr potential participation in the damage of the corneal epithelium after prolonged use of contact lenses in rabbits

High-Resolution MAS 1H NMR Spectroscopic Analysis of Rabbit Cornea After Treatment with Dexamethasone and Exposure to UV-B Radiation

Enzyme histochemistry of corneal wound healing

Xanthine oxidoreductase and xanthine oxidase in human cornea.