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

The amniotic membrane in ophthalmology

Cerebral angiography was inaugurated by Egas Rfoniz of Lisbon in 1926 and has now become one of the standard diagnostic methods of cerebral lesions. Lima’s book is the first systematic treatise on this subject published by the Portuguese school in the English language. The author has been associated as neurosurgeon with RIoniz for more than twenty years, and the combined material of these two investigators comprises more than two thousand angiographies, a numbcr unsurpassed anywhere. Lima corroborates, amplifies and in some rases revises Moniz’ fundamental work which had bcen published previously in the French and German literature. The subject matter is covered in $ell organized and critical fashion, but unfortunately too little attention is paid to the numerous publications on angiography which appeared in Scandinavian, American and German literature, especially after the war. After reviewing the history of angiography, its technique is discussed. Lima advocates surgical exposure of the common carotid artery low a t the neck in preference to the percutaneous technique now practiced in many centers. He performs carotid angiography bilaterally in one sitting under local anesthesia and obtains routinely three lateral films for each injection (the first film to show the arterial phase, the second the early venous phase, and the third the late venous phase). AP projections are rarely used, and stereoscopic films never taken. The next chapter deals in detail with the normal arteriogram and phlebogram obtained by vertebral and carotid injection. Then follows a description of the typical displacements and deformities of cerebral vessels caused by intracranial tumors and, hydrocephalus. I n the next section the angioarchitectonic pattern of cerebral tumors is described. This chapter is particularly interesting and informative since Lima has done much original work on the circulation of meningiomas. The typical double blood supply of meningiomas through branches of the external and internal carotid arteries is discussed, and also the relation of ,angiographic pictures to modification of the circulation time is analyzed. The chapter on cerebral aneurysm is relatively brief but vascular malformations are discussed at length. Angiography offers an important aid i n the diagnosis of cerebral vascular occlusion. Special attention is given to the not uncommon thrombosis of the cervical portion of the carotid artery. This condition produces a characteristic clinical syndrome and can be easily recognized by low cervical carotid angiography.

The Cerebral Cortex of Man

The members of the Management and Therapy Subcommittee assessed current dry eye therapies. Each member wrote a succinct evidence-based review on an assigned aspect of the topic, and the final report was written after review by and with consensus of all subcommittee members and the entire Dry Eye WorkShop membership. In addition to its own review of the literature, the Subcommittee reviewed the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force (ITF) Delphi Panel on Dry Eye. The Subcommittee favored the approach taken by the ITF, whose recommended treatments were based on level of disease severity. The recommendations of the Subcommittee are based on a modification of the ITF severity grading scheme, and suggested treatments were chosen from a menu of therapies for which evidence of therapeutic effect had been presented.

Management and therapy of dry eye disease: Report of the management and therapy subcommittee of the international Dry Eye WorkShop (2007)

Pain associated to mechanical and chemical irritation of the eye surface is mediated by trigeminal ganglion mechano- and polymodal nociceptor neurons while cold thermoreceptors detect wetness and reflexly maintain basal tear production and blinking rate. These neurons project into two regions of the trigeminal brain stem nuclear complex: ViVc, activated by changes in the moisture of the ocular surface and VcC1, mediating sensory-discriminative aspects of ocular pain and reflex blinking. ViVc ocular neurons project to brain regions that control lacrimation and spontaneous blinking and to the sensory thalamus. Secretion of the main lacrimal gland is regulated dominantly by autonomic parasympathetic nerves, reflexly activated by eye surface sensory nerves. These also evoke goblet cell secretion through unidentified efferent fibers. Neural pathways involved in the regulation of Meibonian gland secretion or mucins release have not been identified.In dry eye disease, reduced tear secretion leads to inflammation and peripheral nerve damage. Inflammation causes sensitization of polymodal and mechano-nociceptor nerve endings and an abnormal increase in cold thermoreceptor activity, altogether evoking dryness sensations and pain. Long-term inflammation and nerve injury alter gene expression of ion channels and receptors at terminals and cell bodies of trigeminal ganglion and brainstem neurons, changing their excitability, connectivity and impulse firing. Perpetuation of molecular, structural and functional disturbances in ocular sensory pathways ultimately leads to dysestesias and neuropathic pain referred to the eye surface. Pain can be assessed with a variety of questionaires while the status of corneal nerves is evaluated with esthesiometry and with in vivo confocal microscopy.

TFOS DEWS II pain and sensation report

Gas-permeable scleral contact lens therapy in ocular surface disease.

Purpose.To examine the diagnostic indications and relative merits of a fluid-ventilated, gas-permeable scleral lens for improving vision impaired by irregular astigmatism and for providing a therapeutic environment for managing severe ocular surface disease.Methods.After a review of scleral lens dev

Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty.

The traditional model of dry eye disease based on tear deficiency has presented us with many unanswered questions. Recent studies support the notion that dry eye-like symptoms represent non-specific corneal pain and provide new insights into the mechanisms that sustain the integrity of the optical tear layer. Thus, this enigmatic disease can be viewed with a new perspective, which involves the dysfunctional corneal pain system as a central pathogenetic feature of a series of disorders collectively known today as dry eye.

The Corneal Pain System. Part I: The Missing Piece of the Dry Eye Puzzle

Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens

Purpose To determine if the Boston Scleral Lens Prosthetic Device (BSLPD) reduces symptoms and improves quality of life in patients with severe dry eye from chronic graft-versus-host disease (cGvHD). Methods This is a noncomparative interventional case series reporting 33 consecutive patients with severe dry eye from cGvHD, unresponsive to conventional therapy, who were fitted with the BSLPD. A patient survey was undertaken after lenses were dispensed and worn regarding the effect of scleral lens wear on their symptoms, quality of life, and activities of daily living. The patient population was characterized from a retrospective chart review. Survey data were tabulated. Results BSLPD wear resulted in improvement in pain, photophobia, and general quality of life in nearly all patients, with more than half reporting the highest improvement level for pain (52%) and photophobia (63%), and more than two thirds (73%) reporting the highest improvement level for quality of life. There was improvement in reading and driving in >90% of those who reported previous compromise, with >60% reporting the highest improvement level for each of these activities. Conclusions The BSLPD mitigates symptoms and improves quality of life in patients with severe dry eye from cGHvD.

Perry Rosenthal

Papers

Gas-permeable scleral contact lens therapy in ocular surface disease.

Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty.

The Corneal Pain System. Part I: The Missing Piece of the Dry Eye Puzzle

Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens

Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease.