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General symptoms of visual discomfort may include those linked to DED . DED is the predominant cause of computer vision syndrome , resulting in the reporting of general visual symptoms after prolonged use of digital screens compared to equivalent paper copy tasks . Incomplete blinks rather than a reduction in blink rate appears to be associated with these symptoms . Differentiation from primary DED is on the basis of history informed triggers of dryness and more general symptoms such as the eyes being tired, hurting, feeling heavy, burning, straining, stinging and experiencing photophobia .


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Giombini et al (2021) compared short-term clinical outcomes between IA injection of HA, oxygen ozone (O2O3), and the combination of both, in patients affected by OA of the knee. A total of 70 patients (age of 45 to 75 years) with knee OA were randomized to IA injections of HA (n = 23), or O2O3 (n = 23) or combined (n = 24) 1 per week for 5 consecutive weeks. KOOS questionnaire and VAS, before treatment (pre) at the end (post), and at 2 months after treatment ended (follow-up) were used as outcome measures. Analysis showed a significant effect (p < 0/05) of the conditions (pre, post and follow-up) in all parameters of the KOOS score and a significant effect (p < 0/05) of groups (HA, O2O3 and combined) for pain, symptoms, activities of daily living (ADL) and QOL. The combined group scores were higher compared to the HA and O2O3 groups, especially at follow-up. The authors concluded that the combination of O2O3 and HA treatment led to a significantly better outcome especially at 2-month follow-up compared to HA and O2O3 given separately to patients affected by OA of the knee. This was a relatively small study (n = 24 in the combination group) with a short-term follow-up (2 months).


Tear ferning is correlated with tear film volume and weakly with tear film stability, but seems to be independent of individual tear proteins . Tear ferning changes with contact lens wear have been found to have a moderately high sensitivity (78/4%) and specificity (78/4%) for predicting contact lens tolerance in a clinical setting . However, other studies have found that the tear ferning test had a poor correlation with tear film stability and symptoms in contact lens wearers .

In addition, quantitative evaluation of meibomian gland area visualized by meibography has been performed [417–420]. Such quantitative evaluation has been applied to the diagnosis of MGD as well as to evaluation of the effects of treatment [421,422]. Meibography alone does not appear to be sufficient for the diagnosis of MGD, but instead should be interpreted in the context of other clinical parameters [411,423–425]. The thickness of the lipid layer of the tear film measured by interferometry (LipiView) was found to be related to meibomian gland area determined by meibography . Tear fluid secretion has also been shown to be positively correlated, as a compensatory mechanism, with the area devoid of meibomian glands in patients with MGD .


The MACSQuant Instrument also facilitates the absolute quantitation of cell populations and has a processing rate of up to 10,000 events per second. The instrument was designed for use with MACS Cell Analysis and MACS Separation Reagents in research applications, though common fluorochromeconjugated antibodies and fluorescent reagents from other suppliers can also be used. The relatively small footprint of the MACSQuant Instrument ( cm) in comparison to other commercially available flow cytometers makes the instrument ideally suited to benchtop operation within the laboratory. Also, the instrument has several design features that permit the fully automated processing of cell samples from sample labeling and mixing, through uptake, and magnetic enrichment, to fluorescence analysis. The MACSQuant Instrument can be optionally fitted with the MACS MiniSampler. The MiniSampler is a motorized sample rack holder that can hold tube racks of varying formats including 96-well microtiter plates. The fully automated uptake and processing of multiple samples is possible under control of the MACSQuantify Software thus permitting the user a hands-free, high-throughput operation. Automated maintenance procedures are also a design feature of the MACSQuant Instrument. This includes different system wash programs before each measurement, automatic priming of the instrument, and programs for shutting down the instrument for overnight or long-term storage. After sample uptake, the instrument can analyze fluorescently labeled cells using up to nine or ten optical parameters seven or eight fluorescence and two scatter channels.

The IDEEL questionnaire has 2 items related to visual disturbance including the extent to which a person is bothered by “blurry vision” or “sensitivity to light, glare, and/or wind”. Statistically significant differences in responses to the IDEEL questionnaire scores across varying levels of DED severity have been observed .


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The red color represents the highest density of cells, followed by yellow, then green, and finally royal blue, which represents the cells occurring at the lowest frequency. Statistics Before performing statistical analysis of cell populations it is important to note that the precision and relevance of the analyzed data is dependent on the sample size and choice of statistic, respectively. The MACSQuantify Software can display a summary table of statistical attributes, namely: count, percentages, arithmetic mean, coefficient of variation (CV), minimum/maximum/medium, median, and modal statistics. In addition, since the MACSQuant Instrument performs volumetric cell enumeration the actual cell count can also be displayed with each measurement. Text The MACSQuantify Software Text option is a text box that may be used to enter alphanumeric characters that may be used, for example, to document details about the experiment, the gating strategy, or specific dot plot. This option also allows the user to display several other experimental parameters via the drop-down menu such as experimental information from the sample.


However, all these aspects are rarely inclusion criteria of studies. Also the definition implied that dry eye can occur without ocular surface damage, yet staining is often listed as an inclusion criterion.

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All essential oils tested showed antitumor activity as measured by their effect on cell viability. The most noticeable decrease in viability was shown by S. tortuosum and E. maritimum EOs, as indicated by IC50 average values of 3/29E-03 and 8/59E-04 (for RKO) and 1/85E-03 and 2/72E-03 (for MCF7), respectively. Some of the tested EOs, such as J. turbinata for MCF7 cell line and C. maritimum for RKO cell line, showed lower activity (IC50 average value of 3/85E+1 for MCF7 cells and 8/76E00 for RKO cells, respectively). There are several studies on the antioxidant activity of plant extracts. For example, Aniya and collaborators (2000) investigated the antioxidant and hepatoprotective action in water extracts of A. campestris (from Okinawa Islands), and observed that these extracts provide protection against liver toxicity. The literature available for potential antitumor activity of EOs is more limited, however, there are some studies, about citrus fruits, cherry, mint and herbs that indicate potential of antitumor activity against different types of human cancers, including breast cancer, liver cancer and melanoma. In these studies, this effect is associated with the specific chemical compounds of the EOs, including monoterpenes (Crowell, 1999). It would be interesting to study the role of individual chemical components from the EOs in any potential effects, namely anticancer activity, in their action. For this, it is necessary to analyse in detail the chemical composition of each EO. These would then be evaluated independently and compared to the complex EO mix. Finally, the data here presented indicates that these EOs have an anti-proliferative effect on the cell lines used.

Inflammation of the eyelids can result from infection by, or allergic reaction to, external agents. The clinical features of blepharitis include redness, exanthema, sores, eschar, swelling, and bullous formation. Blepharitis is classified according to its anatomic location. Anterior blepharitis affects the base of the eyelashes, eyelash follicles, and/or eyelid skin. Inflammation of follicles is categorized as marginal blepharitis, whereas that of eyelid skin is blepharo-dermatitis. The pathogenesis of anterior blepharitis is infectious or noninfectious in nature, and so the location and cause of the condition should be considered for diagnosis . Clinical features of anterior blepharitis often overlap those of DED . Recurrent or persistent blepharitis can cause DED, thus observation of the eyelid is important for adequate diagnosis of DED.


Researchers have also used OCT [308,309] and Scheimpflug photography to observe LIPCOF . Using these instruments, additional criteria such as cross-sectional area of LIPCOF or LIPCOF coverage by the tear meniscus can be evaluated [297,308,309]. Conjunctival shrinkage has been proposed as a diagnostic feature of dry eyes ,and has been shown to occur more in patients with dry eye symptoms, less stable tears and with ocular surface staining, but not those with MGD .

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An intact lipid layer may be necessary to prevent tear film evaporation . The tear film evaporation rate is used as an indicator of tear film stability . Evaporation of the tear film has been measured using a number of different techniques including a vapour pressure gradient [176,177], and the velocity of relative humidity increase (resistance hygrometry) within a goggle cup placed over the eye [178–181]. Using these techniques, higher evaporation rates between blinks have been reported to be associated with poor tear film stability , and DED symptoms [179,182,183]. An absent, or non-confluent lipid layer has been determined to be associated with a four-fold increase in evaporation rate , and a two-fold increase in evaporation rate has been reported in patients with keratoconjunctivits sicca . The rate of evaporation of the tear film has also been shown to be higher in the presence of a contact lens, and the effect remains for a period of 24 h after ceasing contact lens wear [184,185]. Since the evaporation rate is dependent on ambient temperature , humidity [175,180,187], and time of day [181,188], and can be affected by evaporation from the skin surrounding the eye, use of tear evaporation rate as a diagnostic and monitoring tool is challenging due to variable measurements.


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EKC, in particular, tends to be accompanied by periorbital edema and significant inflammation that may also involve the extraocular muscles. A follicular response is often noted on the palpebral conjunctiva. Early stage EKC presents with positive pre-auricular lymphadenopathy on the ipsilateral side to the eye that first manifested the conjunctivitis. Approximately one week later, the cornea typically exhibits sub-epithelial infiltrates, which account for symptoms of irritation and pain, often leading to decreased visual acuity that can last months or even years after the infection subsides .


Further, operation of the MACS Cell Enrichment Unit in the instruments is directly controlled by the MACSQuant Analysis Software to enable the fully automated processing and acquisition of samples as well as analysis of the collected data. Automation can further be extended to multisample processing when combined with the MACS MiniSampler for convenient, hands-free operation. Needle arm Cell Enrichment Unit MACS MiniSampler Figure 1/8 Front image of the MACSQuant Instrument, the access cover was made transparent for the purpose of illustration.

Sodium hyaluronate 0/84% is supplied as Gelsyn-3 (formerly Gel-Syn) is supplied 8/4 mg/mL in a 2 mL pre-filled glass syringe. Gelsyn-3 (sodium hyaluronate 0/84%) is injected once weekly for 3 consecutive weeks, for a total of 3 injections.


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Non-invasive breakup time should be performed with a method where as much of the naturally exposed cornea as possible is specularly illuminated with a light source allowing observation of breakup over the whole surface, after a blink. Objective methods are preferred, with three measurements being performed and the median value recorded. Following training, if a patient can no longer refrain from blinking before the tear film breaks up, this is typically counted as the breakup time for that measurement . The lower median breakup value of the two eyes should be considered in making the diagnosis. The cut-off for a positive finding can be as low as 2/7 s for automated algorithms , and up to 10 s for subjective observation techniques .

Saline et al (2009) evaluated the effectiveness of a single ultrasound-guided injection of hyaluronic acid (HA) in patients suffering from OA of the CMCJ. A total of 18 patients with OA of the CMCJ, grade 2-3 Kellgren and Lawrence score, attending the Orthopaedic Department of the University Hospital of Chieti, were enrolled. They underwent clinical evaluation at baseline and after 1 month follow-up, evaluating: grading of pain (VAS at rest and during activities), function (Dreiser Index), grip and pinch strengths Jamar dynamometer), as well as NSAIDs consumption. Each patient received a single ultrasound-guided injection of HA into the articular CMCJ. The results were that pain at rest and during activities decreased from 1/8 +/- 1/07 to 0/5 +/- 0/68 (p < 0/001) and from 8/05 +/- 0/94 to 4/15 +/- 1/42 (p < 0/001), respectively. Dreiser Functional Index showed a significant improvement (+11/59 %; p < 0/004), as well as pulp pinch strength (24/07 %; p < 0/001). The consumption of NSAIDs was also clearly reduced, from 16 to 7 patients (-45 %) and from 2/45 +/- 1/98 to 1/15 +/- 1/30 tablets per week (p < 0/02). Mild local side effects, lasting less than 3 hours, were observed only in 2 cases. The authors concluded that a single ultrasound-guided injection of HA is a safe and effective procedure in the treatment of OA of the CMCJ, with a significant improvement in terms of pain and function. Moreover, they stated that studies with larger samples and longer term follow-up are needed.


Meibomian glands secrete meibum, which contains components of the lipid layer of the tear film. Meibum quantity, quality and expressibility are thought to reflect meibomian gland function. The expressibility of meibum, as an indicator of meibum secretion, is commonly determined by the application of digital pressure to the glands, along the length of the eyelid, through the skin surface of the eyelid [406,431,432], although more standardized procedures for expression have been reported . In the normal eyelid, meibum is clear and readily expressed with gentle pressure. Conversely, the condition of meibum in patients with MGD is varied. In such individuals, meibum can lose its clarity to become cloudy and then opaque and its viscosity can be increased, becoming toothpaste-like and difficult to express in patients with severe MGD. The ranging qualities of meibum as well as its expressibility have been evaluated in various grading schemes. The number and location of expressible glands, as well the response of the glands to different levels of digitally applied pressure, have thus been scored and graded, providing information directly related to meibomian gland condition [416,433–439]. However, the diagnostic value of meibomian gland expressibility and duct appearance has not been established in DED.

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In a randomized double-blind study, Palmieri et al (2021) examined the effect of a highly cross-linked hyaluronic acid (HA), Variofill, alone or in combination with diclofenac sodium or sodium clodronate, for management of bilateral knee osteoarthritis-related pain. A total of 62 patients with symptomatic bilateral medial tibiofemoral knee osteoarthritis (Kellgren-Lawrence grade II and III) and pain in both knees corresponding to a daily visual analog scale (VAS) score greater than or equal to 30 in the month before the beginning of the study were included in this investigation. Patients were divided into 3 groups: group 1, treated with an injection of HA alone (66 mg) into each knee; group 2, treated with an injection of HA (49/5 mg) plus diclofenac sodium (5 mg) into each knee; group 3, treated with an injection of HA (49/5 mg) plus sodium clodronate (5 mg) into each knee. Patients also underwent blood tests for measurement of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) immediately before and at 6-month follow-up. Hyaluronic acid alone and in combination with sodium clodronate or diclofenac sodium produced a significant improvement in mean VAS pain score at 3 and 6-month follow-up. At 6-month follow-up, therapy with HA plus sodium clodronate was the most beneficial in terms of percentage improvement in VAS pain score. A significant improvement in ESR and CRP was observed at 6-month follow-up in each treatment group. No significant difference was observed when the percentage change from baseline related to these parameters was compared among the groups. No drop-out was observed in any group. No serious adverse events were observed.


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The most common clinical sign that is suggestive of ocular surface inflammation is conjunctival redness [338–340]. This is a consistent sign of conjunctival vascular dilatation and reactive change to pathological stimuli. It can occur in any disease with inflammation, not just DED, for example, in response to chemical injury, infective conjunctivitis or allergic conjunctivitis. Ocular redness can be easily detected with a pen torch or standard slit lamp biomicroscopic examination. For the purpose of diagnosis and documentation of treatment effects, more quantitative documentation methods using digital imaging analysis have been developed [341–344].


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Initial exposure generally occurs during infancy or early childhood and produces subclinical infection. However, if exposure occurs in adolescence, it often manifests as infectious mononucleosis. Epstein-Barr virus infection of ocular structures most often results in transient follicular conjunctivitis but can also manifest as DED, keratitis, uveitis, choroiditis, retinitis, oculoglandular syndrome, papillitis, and ophthalmoplegia . Picornaviruses, such as enterovirus 70 and coxsackievirus A24, are highly contagious and often are the cause of epidemics. Like adenoviral conjunctivitis, picornaviruses cause an acute hemorrhagic response, although the clinical appearance is usually more severe. A number of systemic viruses—including as rubeola (measles), rubella (German measles), mumps, and influenza also frequently involve conjunctival infection . In cases where clarification is desired, diagnostic tests with high sensitivity and specificity can help identify forms of viral conjunctivitis in minutes .


Current therapeutic options for spasticity include oral medications such as benzodiazepines, baclofen, and tizanidine that are central nervous system (CNS) depressants used to suppress spinal hyper-excitability, and local injections of botulinum toxin (BTX) used to suppress muscle over-activity. Whereas the oral medications could produce cognitive deficits, fatigue, and muscle weakness, BTX injections produce focal muscle weakness. Therefore, it is necessary to balance the risks and benefits of treatment, which often remains inadequate. Furthermore, these treatments do not directly address muscle stiffness. The authors proposed the “Hyaluronan Hypothesis”, which postulates that the accumulation of hyaluronan within muscles promotes the development of muscle stiffness. They reported that the enzyme hyaluronidase, which hydrolyzes hyaluronan, and is available for off-label clinical use, increases both passive and active joint movement, and reduces muscle stiffness in individuals with upper limb spasticity. These results fill a critical gap in the understanding of muscle stiffness, and present a promising treatment for a vexing and widespread problem. In this study, a total of 20 patients with unilateral upper limb spasticity received multiple intra-muscular injections of human recombinant hyaluronidase with saline at a single visit. The safety and efficacy of the injections, passive and active movement, and muscle stiffness at 8 upper limb joints were assessed at 4 time-points: pre-injection (T0), within 2 weeks (T1), within 4 to 6 weeks (T2), and within 3 to 5 months post-injection (T3). There were no clinically significant adverse effects from the injections.


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Pleiotrophin (PTN) is a secreted heparin-binding, developmentally regulated protein that is found in abundance in fetal, but not mature, cartilage. SDS-page and glycosaminoglycan (GAG) analysis of sulfate-radiolabeled proteoglycans isolated from the medium of mature cultured chondrocytes treated with PTN showed a threefold increase in the levels of proteoglycan synthesis. In contrast, in cultures of fetal chondrocytes, no changes in proteoglycan synthesis were observed. Thymidine incorporation experiments showed a dose-dependent decrease in proliferation of treated cells compared with control cultures, suggesting that pleiotrophin had an inhibitory effect on growth of chondrocytes. Neither FGF or heparin reversed the inhibitory effect of PTN. Capillary electrophoresis of chondroitinase ABC-digested proteoglycans isolated from mature chondrocytes showed 2–4-fold increases in the amounts of the 4S- and 6S-substituted GAG chains for the PTN-treated chondrocytes. Northern analysis showed a twofold upregulation in the mRNA levels of biglycan and collagen type II, but no difference in the message levels for decorin and aggrecan. These results establish that PTN inhibits cell proliferation, while stimulating the synthesis of proteoglycans in mature chondrocytes in vitro, suggesting that PTN may act directly or indirectly to regulate growth and proteoglycan synthesis in the developing matrix of fetal cartilage.

Comparison with the ELISA Technique. Sensors (Basel) 2021;15:19819–19829.


Pay special attention to all warnings displayed on the instrument. Failure to read and follow these guidelines could lead to improper or incorrect usage and result in damage to the instrument. Improper usage could also cause severe personal injury, death, unpredictable results, instrument malfunction, and premature wear to components shortening the lifetime of the instrument. Such actions may void your warranty. Keep the user manual and any other safety and operating instructions provided with the instrument in a safe place accessible to all users for future reference.

The user will be prompted to save any changes to the workspace before this action is performed. Open Workspaces, Instrument Settings, Experiments, Analysis templates, and/or Data files, depending on the user access rights set by the administrator. Click to save Workspaces, Instrument settings, Experiments, Reagents, and Analysis templates, depending on user access rights set by the administrator. Import data files in the FCS file compression format.


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According to a review of the literature in the journal Clinical Evidence (Scott and Kowalczyk, 2006), compared with placebo, intra-articular hyaluronan and hyaluronan derivatives may improve knee pain and function compared with placebo at up to 13 weeks after injection, but may have no longer-term benefits. The review stated that this conclusion is based upon low-quality evidence. The assessment also found that, compared with intra-articular corticosteroids, hyaluronan may be more effective than intra-articular corticosteroids at reducing pain at 5 to 13 weeks, although they may be as effective as each other in the shorter term. According to the review, this conclusion is based upon very low-quality evidence. The assessment also noted that there is no evidence on the effectiveness of subsequent courses of hyaluronan, and if diminishing returns exist.

Fig. 3. PAGE analysis of chondroitin sulfate/dermatan sulfate GAGs

In a comparative study in human patients with knee OA, the group that received IA injection of HA in combination with oxygen ozone showed better outcome than HA or ozone administered separately, however, the applications were once-weekly for 5 consecutive weeks. These investigators stated that further studies are needed to clarify, including an ozone group, which may consider one of the limitations of the present study. Because IA route in dogs generally requires sedation and/or anesthesia, another option would be rectal insufflation, as used in human patients with rheumatoid arthritis. Another drawback of this study was the use of heterogeneous groups of dogs, which made difficult the kinetic evaluation. Furthermore, the dogs were evaluated walking, because of the disease the dog may be unable to trot or have difficult to gait trial repetition, despite trotting gait be considered more sensitive than walking gait to lameness detection.


Osmolarity should be assessed with a temperature stabilised, calibration checked device. In the case of the Tearlab, temperature stability is achieved by having the device powered on for a sufficient period of time with test cards adjacent to the device for at least 30 min. Seat the patient with chin tilted upward and eyes directed toward the ceiling. Place one hand on the face for stabilization, as appropriate. Do not pull the eyelid down or away from the eye. Sample from just above the lower eyelid tear meniscus, being careful not to press inward to avoid contact with the globe during collection. The difference between the eyes as well as the absolute measures can be diagnostic [170,171]. A positive result is considered to be ≥ 308 mOsm/L with the currently available device in either eye [13,15], or an interocular difference >8 mOsm/L .

In the clinical setting, symptoms or other subjective reports are typically captured through the patient case history [55,56]. Symptoms reported during non-scripted verbal interviews are very difficult to standardize and quantify. To enhance standardization in clinical research, symptoms are typically gathered through the use of questionnaire instruments that are most often self-administered by the patient or research subject without input from the clinician or researcher. In DED, these instruments either measure ocular surface discomfort or vision symptoms associated with DED, the impact of DED on everyday function, or health-related quality of life. Table 2 gives a summary of the most frequently used DED questionnaires, their original and recent citations, and the forms of validation supported by the literature cited.


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Samson DJ, Grant MD, Ratko TA, et al. Treatment of primary and secondary osteoarthritis of the knee. Evidence Report/Technology Assessment No. 157. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2007.


An abnormal multicolored interferometric fringe is observed. A video of lipid layer imaging is also available on the TFOS website.

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There appear to be no correlation between blink speed and either DED symptoms or tear film stability. However the upper lid velocity is positively related to LIPCOF [295,473].


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Kirwan (1997) reviewed 10 clinical trials of hyaluronan of the knee joint. The review found slightly greater benefit from the injections versus placebo at 1 to 6 months after treatment. Of 4 subsequently published randomized controlled trials (RCTs), 3 (Lohmander, 1996; Corrado et al, 1995; Formiguera, 1995) found no significant difference versus placebo at 2 to 5 months after treatment, but both active and placebo groups improved compared with baseline. One of the trials (240 people) included a subgroup analysis of people aged over 60 years with moderate to severe symptoms; these benefited more with active treatment than placebo (Lohmander, 1996). The 4th subsequent RCT, involving 100 people, found significant benefit on a standardized pain assessment tool (the Lequense index) with hyaluronan versus placebo, both at 5 weeks and 4 months (Huskisson, 1999). Another RCT also found a trend toward greater pain relief and functional recovery in patients treated with intra-articular hyaluronan versus placebo injection, but the differences between the 2 groups were not statistically significant (Tamir, 2001).


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Footnotes: Abbreviations in alphabetical order: ADDE = Aqueous Deficient Dry Eye, CLD = Contact Lens Discomfort, MGD = Meibomian Gland Dysfunction, QoL = Quality of Life. CID = clinically important difference, GVHD = Graft Versus Host Disease, NEI-VFQ = National Eye Institute - Visual Function Questionnaire.

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For subtype classifying of DED and to inform appropriate management, the presence of blepharitis, and their blink rate and completeness when a patient is performing a task such as completing a DED questionnaire, unaware that the eye care practitioner is observing them, should be noted. Lipid thickness should be observed with an interferometric technique and the pattern graded. Ideally meibography should be performed along with duct observation and expressibility .


Filamentary keratitis is generally a chronic corneal condition, characterized by fine strands of degenerated epithelial cells and mucus attached to the cornea at one or both ends . Patients often experience foreign body sensation, grittiness, discomfort, photophobia, blepharospasm, and increased blinking. ADDE is the most common ocular condition associated with filamentary keratitis and best-practice management involves treating the underlying DED and potential mechanical removal of the corneal filaments . Interstitial keratitis is any non-ulcerating inflammation of the corneal stroma, often with vascularisation, but without involvement of either the epithelium or endothelium. The underlying causes are generally infectious or immune-mediated . Neurotrophic keratitis from dysfunction of the ophthalmic division of the trigeminal nerve caused by conditions such as diabetes mellitus, ocular herpes simplex, neoplasia, and ophthalmic surgery is associated with reduced aqueous production . However, treatment after the early stages of the disease can require more radical treatment than primary DED such as antibiotics, antivirals, autologous serum and steroids . Bullous keratopathy is a pathological condition in which small vesicles, or bullae, form in the cornea due to endothelial dysfunction. These blister-like formations can undergo painful ruptures and disrupt vision. Treatments include hyperosmotic eye drops to reduce swelling (5% sodium chloride), amniotic membranes, bandage contact lenses to reduce discomfort, antiglaucoma medications to reduce the flow of fluid into the cornea, and corneal transplantation to replace the damaged tissue .

The patients were evaluated on a verbal pain rating scale 1, 3, and 6 months after the second injection. The Kruskal-Wallis test was used to detect statistically significant differences among the 3 groups, and the analysis was refined with the Friedman test. Overall, although injections induced analgesia at 1 month, these effects were reduced at 3- and 6-month follow-ups. No statistical differences were found between the 3 treatment groups (after 1 month, p = 0/71; after 3 months, p = 0/69; after 6 months, p = 0/66). The Friedman test showed a significant decrease in treatment score as a function of time in groups B and C (p = 0/015) but not in group A (p = 0/074).


Also, the laser light excites the fluorescent molecules on fluorescentlylabeled cells and the light emitted from each excited fluorochrome is measured by color detectors after passing through the respective filters (fluorescence channels). Finally, the cells are discarded into the waste container Displaying flow cytometric data Flow cytometry data can be displayed in four different formats by the MACSQuantify Software: dot plot, histogram, density plot, and statistic. A text box can be used to enter additional information. Each category is briefly discussed below; however, it is worth noting that data are normally visualized as one-parameter histograms or twoparameter dot plots. Dot plot A dot plot may also be referred to as bivariant display, scattergram or in some cases bitmap. In this form of analysis each cell event is represented as a single dot on a two-axis scale chart. The position of the dot on the x/y scale is dependent on the intensities of the measured parameters for that cell/event. Characterization of a cell population is typically achieved by displaying a dot plot where side-scatter (SSC; y- axis) is plotted against forward-scatter (FSC; x-axis). Granulocytes Monocytes Lymphocytes Figure 1/1 A two-parameter dot plot showing side-scatter plotted against forward-scatter of human peripheral blood mononuclear cells (PBMCs).

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The DEQ has 4 questions related to visual disturbance, including the frequency of visual changes, how noticeable the visual disturbance is in the morning and at night, as well as how much the visual fluctuation bothers the respondent. Visual symptoms generally increase in intensity over the day, suggesting that open-eye conditions might affect symptom progression . One study using the DEQ found that 10% of patients with non-Sjögren syndrome DED and 30% of patients with Sjögren syndrome complained of impaired vision while others reported that between 42% and 80% of patients with primary Sjögren syndrome experienced “disturbances in daily vision” [18,87,88].


A: P1 region was defined to remove dead cells and debris. B: A region P2 was defined within gate P1 to select for viable CD34 + cells. Any remaining dead cells are positive for PI and are excluded from the region P1\P2. C: The region P3 was defined within gate P1\P2 to select for all viable CD34 + cells. Region P3 was renamed CD34 target cells for added clarity. D: The final gate is displayed, namely: P1\P2\CD34 target cells. The corresponding statistics are shown by the adjacent table. E: To demonstrate the gating strategy all defined regions were color-coded are display on a single two-parameter dot plot. P1 is green; P1\P2 is red; P1\P2\CD34 target cells is blue.

Su et al, demonstrated that areas of ocular surface cooling and breakup were co-localized , and Li et al, reported a direct relationship between FBUT and ocular surface cooling, implying that localized increases in evaporation are contributing to tear film thinning and breakup . Using a customized ocular surface thermography device, a method has been demonstrated in which the exact area showing temperature reduction can be determined by analysing a series of images over a period of 9 s . From this analysis, a “thermal breakup area” and “thermal breakup time” can be reported. Furthermore, the subjective sensation of discomfort has been reported to occur earlier in the interblink period in patients with DED than in controls (during forced eye opening), and that the subjective symptoms were correlated to low corneal temperatures and enhanced tear evaporation . Sensitivity and specificity values of around 80% have been reported [160,161].


This finding is termed heteroscedasticity, or increasing variation with increasing value . Keech et al, further reported that the variability of tear osmolarity of normal subjects was indistinguishable from the analytical variability of measurements of a control solution of known osmolarity, suggesting that normal individuals retain an effective tear film with little variation from blink-to-blink and day-to-day .

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Finn et al (2021) stated that palindromic rheumatism is characterized by multiple recurrent episodes of arthritis and peri-arthritis (mono- or oligo-articular) that may last hours or days, disappearing without sequels. These investigators reported a 69-year old male with a history of hypertension and a presumptive diagnosis of gout due to recurrent episodes of arthritis and peri-arthritis in the last 30 years. They involved at least 2 joints, lasted few days and were self-limited. The patient was admitted due to arthritis and peri-arthritis of both wrists, knees, ankles, elbows and hands. He presented with fever (38 to 39 degrees C), intense articular pain and anorexia. With a presumptive diagnosis of palindromic rheumatism and the lack of response to NSAIDs, methylprednisolone 20 mg/od per os was started, with an excellent response.


Meibography scales have been found to be highly reproducible [413,428], Meibography has revealed that changes in meibomian gland morphology are less pronounced in patients with ADDE than EDE [427,429]. However, shortening of meibomian gland ducts was frequently detected in wearers of contact lenses who complained of DED symptoms . Establishing the diagnostic value of meibography in DED requires further study.

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The changes in this variance indicate the instability in image quality, which is directly related to the quality of the tear film, and this has been used as an estimate of the NIBUT. This technique has been further refined by Downie using the E300 corneal topographer (Medmont International Pty Ltd, Victoria, Australia) to measure Tear Film Surface Quality Break-up Time . The algorithm used identifies and eliminates images with excessive movement and is able to recognize shadows arising from eyelashes.


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Sensitive and specific diagnostic and prognostic biomarkers for prostate cancer (PCa) are urgently needed. Urine samples are a non-invasive means to obtain abundant and readily accessible "liquid biopsies". Herein we used urine liquid biopsies to identify and characterize a novel group of urine-enriched RNAs and metabolites in PCa patients and normal individuals with or without benign prostatic disease. Differentially expressed RNAs were identified in urine samples by deep sequencing and metabolites in urine were measured by mass spectrometry. The mRNA and metabolite profiles were distinct in patients with benign and malignant disease. Integrated analysis of urinary gene expression and metabolite signatures unveiled an aberrant glutamate metabolism and tricarboxylic acid (TCA) cycle node in prostate cancer-derived cells. Functional validation supports a role for glutamate metabolism and glutamate oxaloacetate transaminase 1 (GOT1)-dependent redox balance in prostate cancer, which can be exploited for novel biomarkers and therapies.

Each one mL of Visco-3 contains 10 mg of sodium hyaluronate (hyaluronan) dissolved in a physiological saline (1/0% solution). The sodium hyaluronate (hyaluronan) is extracted from chicken combs. Sodium hyaluronate (hyaluronan) is a polysaccharide containing repeating disaccharide units of glucuronic acid and N-acetylglucosamine. Supplied as a sterile, non-pyogenic solution in 2/5 mL prefilled syringe (FDA, 2021). See Appendix for dosing information.


Migliore et al (2021) evaluated the mid-term pain-relief effect of an ultrasound-guided injection of HA combined with a high concentration of sorbitol (SynolisV-A (ANTI-OX-VS)) in patients suffering from symptomatic hip osteoarthritis. Lequesne index, Health Assessment Questionnaire (HAQ), pain reduction, Global Patient Assessment (GPA), Global Medical Assessment (GMA) and reduction in monthly analgesic consumption were assessed during the 12-month follow-up after the injection. A total of 20 patients were enrolled in the study and received 1 IA US-guided injection of 2 syringes of ANTI-OX-VS into the target hip; 11 drop-out patients were registered, of whom 2 were for loss of efficacy at 6 months, 1 for loss of efficacy at 9 months and 8 patients for severe co-morbidities. Mean scores of all clinical parameters evaluated at each control visit were significantly different when compared with baseline mean value. No systemic adverse events were observed. Even though the sample size of this study was limited, the results suggested a durable good efficacy of a 4-ml single injection of ANTI-OX-VS in hip OA, at least for the patients who completed the study. The authors concluded that a larger number of patients and an RCT are needed to confirm these data, investigating also the predictive factors of clinical response to ANTI-OX-VS.

No statistically significant differences in foot pain were found between the groups at 3 months. There were few statistically significant differences in the secondary outcome measures. Overall, the incidence of adverse effects was not significantly different between groups. The authors concluded that an intra-articular injection of hylan G-F 20 is no more effective than a placebo in reducing symptoms in people with symptomatic first MTPJ OA.


In general, the OSDI is the most widely used questionnaire for DED clinical trials. The OSDI measures frequency of symptoms, environmental triggers and vision related quality of life. Many other questionnaires have established concurrent validity against the OSDI in recent publications. The consensus view of the committee was to use the OSDI due to its strong establishment in the field or the DEQ-5 due to its short length and discriminative ability . The continuous nature of visual analogue scales is attractive for clinical trials compared to discrete Likert-based question rating, so questionnaires such as the severity scale of the Symptoms Analysis in Dry Eye (SANDE) should be considered for repeated comfort assessment.

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Oily substances spread to form a thin layer on the surface of water. Exposure of such an oily layer to adequate light results in the generation of an interferometric fringe pattern from interference from the front and back surface refractive index change reflections (from the interface with the air and the muco-aqueous tear film phase respectively). The superficial oily layer of the tear film is thought to retard evaporation of the tears, and, with the rest of the tear film, provides an optically smooth surface over the cornea [148,175,393]. The lipids produced by the meibomian glands usually distribute dynamically from the inferior to the superior region over the ocular surface and then stabilize shortly thereafter .


TriVisc is administered by intra-articular injection as 3 doses, one week apart. TriVisc has the same chemical composition as GenVisc 850, except that GenVisc 850 is administered under a weekly 5-injection regimen of 2/5 ml per injection. Since TriVisc is of identical chemical formulation to GenVisc 850 (previously approved under P140005), all of the nonclinical studies used to provide evidence of the reasonable assurance of the safety of GenVisc 850 apply directly to TriVisc. The effectiveness of TriVisc was established from various nonclinical comparison studies of TriVisc and VISCO-3, which as the same indications for use as TriVisc and is also administered under a weekly 3-injection regimen of 2/5 ml per injection.

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.


Contact lenses can induce dry eyes (termed CLIDE) and appropriate management strategies should be employed to minimize these [495,574]. This should be distinguished from people who have diagnosed primary DED and wish to wear contact lenses where, as well as the selection of lens modality and material, non-preserved DED treatments should be considered .

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As in the previous TFOS DEWS definition of DED , the current TFOS DEWS II definition for DED describes the presence of ocular surface symptoms and other signs of DED . Although the relationship between symptoms and signs of DED is not linear and varies across individuals and types of DED , the ability to accurately quantify ocular surface symptoms is an important screening tool that can assist in establishing the medical necessity for additional DED evaluation. It is also critical for monitoring the progression of the condition and response to treatments. In this regard, symptom measurements are very similar to clinical signs of DED. It is therefore recommended that a validated symptom questionnaire be administered at the beginning of the patient interaction.

Review of Ophthalmology features clinically relevant information on surgical technique, new technologies, disease diagnosis and management.


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The most commonly used ocular surface immune marker is HLA-DR expression, a Class-II MHC antigen, which indicates a loss of the normally immune-suppressed environment of the ocular surface. Epstein has recently published standard operating instructions for impression cytology, for use in clinics and in clinical trials . It was reported that sufficient conjunctival epithelial cells could be harvested for the quantification of HLA-DR using a suitable impression membrane, for example, the commercially available Eyeprim™ membrane (Opia Technology, Paris, France). The precision/repeatability of HLA-DR expression was studied and it was noted that collection, storage and shipment of specimens from distant sites were successful and storage of specimens for up to 30 days (with refrigeration) before processing did not affect results. Since the centralized laboratory was able to track large number of masked samples reliably, the authors suggest that this tool is suitable for use in randomized controlled trials of DED.

Initial work examined the optical and visual impact of tear breakup during periods of non-blinking by quantifying vessel contrast in the fundus images and by monitoring the psychophysical contrast sensitivity and the spatial distribution of tear thickness changes by retroillumination [107,108]. Advances in wavefront aberrometers has enabled assessment of real-time changes in the ocular optics by evaluating refractive anomalies at multiple sites over time. Laser in situ keratomileusis (LASIK)-related dry eyes had greater optical aberrations due to increased tear film irregularity, compared to healthy controls . Serial measurements of higher order and double pass (objective scatter) aberrations after blinking in patients with DED is associated with increased HOAs resulting, in part, from superficial punctate keratitis (SPK) overlying the optical zone [110–112].


Patients were randomized into 2 treatment groups: one underwent meniscectomy alone, whereas the other also received an injection of 3 ml HA at the end of the procedure. All patients were evaluated at baseline and then at 15, 30, 60, and 180 days using the following tools: IKDC subjective, KOOS, VAS for pain, VAS for general health status, and Tegner scores. The trans-patellar circumference and active and passive ROM were also recorded during the follow-up evaluations. No major AEs were reported using HA post-operatively. A statistically significant increase in all the clinical scores was reported in both treatment groups, but no significant intergroup difference was documented at any follow-up evaluation. No difference was observed also in the objective measurements. The mean time to return to full sports activity was not different between groups, and a comparable satisfaction rate was recorded in both treatment groups. The authors concluded that early post-operative viscosupplementation did not provide significant clinical benefits after arthroscopic meniscectomy. They stated that despite the lack of major AEs, the administration of a single HA injection at the end of the surgical procedure is not a successful strategy to provide either faster functional recovery or symptomatic improvement after meniscectomy.

The corneal epithelial barrier can be compromised in the setting of DED, and manifest clinically as punctate epithelial keratopathy/erosions by fluorescein staining, most prominently in the inter-palpebral zone. Other epithelial changes in DED can include filaments, epithelial ridges and, in late stages, keratinization. The epithelial barrier integrity, however, can be compromised due to other non-DED etiologies, which can also lead to epithelial changes and corneal fluorescein staining (Table 7). These conditions often co-exist with DED and may contribute to the OSD. It can sometimes be challenging to determine whether the main underlying reason for the epithelial disease is DED, another etiology, or both.


Physical therapy includes general conditioning, muscle strengthening, and range of motion exercises. In addition, durable medical equipment such as devices for ambulation assistance, appropriate footwear, and bracing should be considered if appropriate.

Segregation of data (such as tear osmolarity or stain grade) for diagnosis concepts: a) representation by overlapping histograms. True positives (TP) and false positives (FP) are represented by the portion of the affected and unaffected distributions to the right hand side of the cut-off (A). True negatives (TN) and false negatives (FN) are represented by the portion of the affected and unaffected distributions to the left hand side of the cut-off (A).


Sodium fluorescein may be instilled to enhance visibility of the tear film, when the test is referred to as the fluorescein breakup time (FBUT); however, fluorescein reduces the stability of the tear film and therefore the measurement may not be an accurate reflection of its status [117,118]. The fluorescein can be instilled in varying volumes and concentrations using either a micropipette, or more commonly impregnated strips . Since controlling the volume instilled with strips may be difficult, the use of narrow (1 mm) strips and dry sterile applicators have been proposed [118–121]. A standardized methodology is also important and instructions are generally given to blink naturally three times and then to cease blinking until instructed . The reference value for DED diagnosis when fluorescein is used ranges from a cut-off time of less than 10 s , to less than 5 s when smaller, more controlled volumes of fluorescein are used [123,124]. The sensitivity and specificity of the test have been reported to be 72/2% and 61/6%, respectively, in individuals with Sjögren Syndrome ; however, mild and moderate DED patients have a broad range of FBUT values and the diagnostic value is less certain for these DED sufferers [13,125]. A significant downfall of the measurement of FBUT is its dependence on subjective assessment by the observer and attempts have consequently been made to automate the measurement [126,127]. Despite the drawbacks of using fluorescein to assess tear film stability, FBUT still remains one of the most commonly used diagnostic tests for DED in clinical practice [128–132].

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The most appropriate test order and techniques to conduct these tests in a clinical setting have been identified, if the triaging questions (Table 6) do not identify a possible different diagnosis which needs further investigation first. Critical, diagnostic tests (symptoms, NIBUT, osmolarity and corneal/conjunctival/lid margin staining) have been differentiated from tests that inform subtype classification aetiologies (MGD imaging/observation and expression, lipid thickness, and tear volume tests).

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Eye involvement is common in patients with systemic autoimmune diseases, particularly rheumatoid arthritis, Sjögren syndrome, seronegative spondyloarthropathy, and antineutrophil cytoplasmic antibody-associated vasculitis. The eye is a privileged immune site, but commensal bacteria are found on the ocular surface. Eye injury may be inflammatory, vascular or infectious, as well as iatrogenic, but DED can also be a presenting symptom. Over half of newly presenting DED cases to a tertiary centre were secondary to a known (48%) or undiagnosed (5%) inflammatory disease, primary thyroid disorder, Sjögren syndrome or rheumatoid arthritis . Sjögren syndrome is considered a sub-classification of DED , but requires specific diagnostic differentiation from other forms of DED to facilitate appropriate interdisciplinary treatment and allow monitoring of potentially life-threatening complications. Unfortunately the average time to diagnose primary Sjögren syndrome from symptom onset is 6/5 years , despite being an independent risk factor for non-Hodgkin lymphoma , and the most highly associated risk factor among all rheumatic diseases for malignancy .

The secondary end-points included 3- and 6-month change in the WOMAC pain (0 to 50) and WOMAC total (0 to 240) and patient's global assessment (PGA). Patient's self-assessment of treatment efficacy (0 to 3) and analgesic consumption were obtained at months 3 and 6. An intent-to-treat analysis was performed. Mean (SD) age was 60/7 (13/9) years, and mean BMI was 28/6 (5/0). Kellgren-Lawrence radiological grade was I/II and III/IV in 13 and 27 of the subjects, respectively. The average WOMAC pain and WOMAC total scores at baseline were 21/5 (9/8) and 89/9 (42/8), respectively; 39 patients completed the follow-up. HAnox-M-XL was well-tolerated; 2 patients experienced knee pain after injection, which resolved within 3 days. No treatment-related severe adverse event was reported. Mean (SD) variations in WOMAC pain and WOMAC total scores were -8/2 (8/9) and -38/4 (35/6), respectively, at month 6 (p = 0/001); PGA decreased from 5/5 (2/0) to 3/0 (2/2) (p = 0/006). Efficacy was rated as good or very good in 76/9 % of the cases. Most of the regular analgesics users decreased their consumption.


Since tear film stability can be affected by fluorescein, temperature, humidity and air circulation, non-invasive breakup time (NIBUT) measurements have become more popular in both clinical practice and research. Many of these techniques involve the observation of the specular reflection of an illuminated grid pattern from the tear film , and these typically result in longer measured values of time to breakup than stability assessment techniques involving fluorescein instillation [118,134,135].

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GVHD is an immune-mediated inflammatory disease that occurs following allogeneic hematological stem cell transplantation and causes destruction of host tissues by immunocompetent cells from the donor. Typical ocular complications in the acute form of the condition are pseudomembranous conjunctivitis and acute hemorrhagic conjunctivitis in 12–17% of cases [570,571], whereas 60–90% with the chronic form develop ocular symptoms of DED , perhaps due to tear fluid levels of receptor agonist IL-8/CXCL8 and interferon inducible protein IP-10/CXCL10 . Ocular symptoms can be minimised by a stepwise approach to treatment involving topical anti-inflammatory medications and autologous serum tears, but patients must be monitored closely, as they are prone to serious ocular complications such as corneal perforation and endophthalmitis .

The MACSQuant instruments feature a multitude of design features that enhance the capabilities and handling of the instruments. The MACSQuant Analyzer and MACSQuant Analyzer 10 have been designed for optimized analysis with fluorescently conjugated antibodies, while the MACSQuant VYB is designed for optimal analysis of fluorescent protein expression, but with any of the instruments there are many additional built in features. The instruments were designed with automation in mind and for use with MACS Control reagents combinations of fluorescence antibody conjugates supplied in an optimized format for the rapid flow cytometric analysis of cell separations performed with MACS Technology. The automated uptake of samples using the needle arm permits measurement of a pre-defined sample volume, which in turn permits an absolute quantitation of cells in a sample. According to their fluorescence labeling, different cell populations can therefore also be quantified. A brief summary of the main design features of the MACSQuant Instruments is given below Fluorescence cell analysis First and foremost, the MACSQuant Instruments are flow cytometers comprised of nine or ten optical channels for the measurement of fluorescence signals and the relative size and relative granularity of cells. In conjunction with the MACS MiniSampler, the automated analysis of multiple samples can be performed with ease. The MACSQuantify Software performs all common functions for the presentation and statistical analysis of collected data.


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Agency for Healthcare Research and Quality (AHRQ). Managing osteoarthritis: Helping the elderly maintain function and mobility. AHRQ Research in Action [newsletter]. Issue 4. Rockville, MD: AHRQ; May 2002.

In a pilot study, Cleary and colleagues (2008) examined the potential effectiveness of HA injection therapy in the treatment of lumbar facet joint arthritis. A total of13 patients with symptomatic lumbar facet joint arthritis who met the inclusion criteria were prospectively recruited. Pre-treatment evaluation of patients was by questionnaire, including the VAS and Oswestry Disability Questionnaire. A single injection of HA into affected facet joints was then performed, with correct placement confirmed on fluoroscopy. Patients were similarly evaluated 6 weeks after treatment. A total of 18 facets were injected with HA. At 6-week follow-up, there was no significant improvement in pain when measured on the VAS. There was also no significant improvement in the Oswestry Disability Questionnaire. The authors concluded that preliminary results from this pilot study did not demonstrate any benefit of viscosupplementation in the management of symptomatic lumbar facet joint arthropathy.


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Meniscometry describes assessment of the tear meniscus and may take the form of a height, or a cross-sectional volume metric. The tear menisci serve as reservoirs, supplying tears to the precorneal tear film . The majority of tear fluid is contained within the menisci , formed by the tears lying at the junctions of the bulbar conjunctiva and the margins of both the upper and lower eyelids. The quantitative assessment of the tear menisci is, at present, the most direct approach to study the tear film volume. Slit-lamp techniques to study tear meniscus height (TMH), curvature (TMR), and cross-sectional area (TMA) are widely used in clinical practice and show good diagnostic accuracy and correlations with other DED tests [198,199]. However, this approach is operator-dependent and has important limitations, mainly related to fluorescein instillation and dependence on time-from-blink, which have potential impact on the tear film characteristics. The simplest type of slit-lamp meniscometry, based on judging the meniscus height by comparison to the variable slit-lamp beam height, has shown poor inter-visit repeatability . Specialized meniscometry systems, equipped with a rotatable projection system that includes a target comprising a series of black and white stripes, a half-silvered mirror, and a digital video recorder, have been developed to facilitate simple and dynamic visualization of the tear meniscus, without the need for fluorescein instillation [200–202]. Meniscometry can be influenced by time after a blink, measurement locus along the lid margin, time of day, temperature, humidity, air speed, and illumination [2,66,203].

Lab-on-a-chip systems capable of evaluating multiple biomarkers simultaneously are being developed by several companies and hold promise for the differential diagnosis of DED as well as systemic diseases . While regulators to date have shown reluctance in approving diagnostic panels in the case of OSD, the availability of these technologies are anticipated to be of transformative value to the ophthalmic communities. Future developments will include the creation of a multiplex tear assay device that incorporates the collection and handling of sub-microliter amounts of tear [588,589]. Since ocular surface oxidative stress is an important trigger of inflammation , another exciting development would be the evaluation of diagnostic tools for the assessment of reactive oxygen species or oxidised products in DED. Technology is needed to determine key pathophysiological indicators of dry eye, such as osmolarity and inflammation, over the whole ocular surface in real-time within the inter-blink interval to better understand the predicated localized changes and how they impact DED .


Few studies have monitored changes in DED signs and symptoms over time. New electronic technologies, such as smartphones or other handheld devices, have been tested recently to capture symptom information in “real time” rather than rely on reports from a recall period, thus aiding patient monitoring .

Decreased mucin production is associated with the severity of LIPCOF , and LIPCOF are significantly correlated with lid wiper epitheliopathy [235,298]. LIPCOF may be related to completeness of the blink , blink speed and tear film viscosity .


These elements suggest that the PRT test provides an indirect but realistic measure of the resting tear volume [231,232]. However, some authors have reported no significant correlation between the PRT test and tear volume determined with previously established methods such as TMH measurement or fluorophotometry , and poor correlation between PRT test results and DED symptoms . Conflicting data, from weak , to strong , agreement, have been recently published on the correlation between the PRT test and Schirmer test. In clinical practice, an arbitrary cut-off value of 20 mm has been adopted to differentiate DED with and without aqueous deficiency using the PRT test . A cut-off of 10 mm gives a sensitivity of 25% and specificity of 93% . Doughty et al. reported small and not statistically significant differences between PRT performed with open or closed eyes .

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A recent review of the literature identified 163 articles published since the year 2000 relevant to the use of tear osmolarity in the diagnosis of DED . Hyperosmolarity of the tear film on the ocular surface causes a significant increase in interferon gamma, in the absence of large increases from other Th1, Th2 and Th17 cytokines, which can induce epithelial cell apoptosis through the JAK/STAT signalling pathway to induce cell death . Tear osmolarity has been demonstrated to have the highest correlation to disease severity of clinical DED tests , and has been frequently reported as the single best metric to diagnose and classify DED [12,13,246]. However, other studies have indicated current measurement techniques to be highly variable . Osmolarity generally increases with disease severity , classified as normal (302/2 ± 8/3 mOsm/L), mild-to-moderate (315/0 ± 11/4 mOsm/L) and severe (336/4 ± 22/3 mOsm/L). More severely affected subjects exhibit both an increased average and increased variability between eyes and between visits [11,170], making the marker heteroscedastic . Various cut-off values for DED have been proposed in the literature, from 305 mOsm/L , to 316 mOsm/L , with reported sensitivities ranging from 64% to 91% [15,23,249,250], specificities from 78% to 96% [249,251], and positive predictive values ranging from 85% to 98/4% [249,252]. These data support the 316 mOsm/L cut-off as a specific threshold to better differentiate moderate to severe DED, or when used in parallel with other specific tests, while the 308 mOsm/L cut-off has become a widely accepted, more sensitive, threshold for use in routine practice to help diagnose mild to moderate subjects [13,15].


An in-depth review of the evidence relating to osmolarity testing in the diagnosis of DED is provided in Section 6/5.1/1; however, it is also important to consider how spatial and temporal variations in tear osmolarity might affect tear film stability. There is greater inter-eye variability of osmolarity in DED than in normals [12,15,169], and the inter-eye differences increase with disease severity . Moreover, this inter-eye variability has been shown to substantially reduce over time with successful treatment of DED .

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As even non-invasive tests of DED require alternation of blinking or bright illumination, the sequence of testing can affect the results. It is recommended that the tests are performed from the least to the most invasive .


Medications which can cause DED are noted in the TFOS DEWS II Epidemiology report

Genovese MC. Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment.

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Concomitant psychosocial issues have been associated with DED. Patients with DED have been shown to have increased prevalence of sleep and mood disorders . Anxiety and depression have also been reported with increased frequency in DED patients in a variety of studies [576–578]. In one population-based cross-sectional study, of over 6000 women, these findings were similarly confirmed. Subjects with a diagnosis of DED were more likely to experience severe psychological stress [odds ratio (OR) 2/5], depressive mood [OR 1/5], and anxiety [OR 1/5] . In another large series of over 7000 DED patients, the adjusted OR of DED and anxiety was 2/8 and DED and the OR for depression was 2/9 . Beyond depression and anxiety, it has been suggested that DED can lead to neuropathic ocular pain and this has been shown to occur with greater frequency in patients who also have comorbid chronic pain syndromes [333,581]. Post-traumatic stress disorder has also been associated with DED and may have a link via treatment medication use or the underlying disease process [61,582]. Neuropathic pain can be differentiated from a disease mechanism through the use of anaesthetic , although this has not been reported in relation to DED symptoms.


A small portion of the marginal conjunctiva of the upper and lower lid acts as a wiping surface to spread the tear film over the ocular surface [379,380]. This contacting surface at the lid margin has been termed the 'lid wiper' . The normal lid wiper is rich in goblet cells , and appears to be the most sensitive conjunctival tissue of the ocular surface . Lid wiper staining with dyes such as fluorescein and lissamine green, which occurs principally in DED patients [298,299,379,383,384], has been termed lid wiper epitheliopathy (LWE) or upper lid margin staining [379,385,386]. It has been proposed that LWE is related to increased friction (direct contact between surfaces) throughout blinks [298,379,383,384], although modelling of the tribology suggests that tear film viscosity-induced hydrodynamic forces at the start of each blink are the principal cause . Boundary lubrication may therefore play a key role in reducing dry eye . LWE occurs on the upper and lower lids, but most studies report only upper LWE. Lower LWE in contact lens wearers has been found to be associated with DED symptoms in some studies , but not others [298,299].

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The Diagnostic Methodology Subcommittee set out to first identify tests used to diagnose and monitor dry eye disease (DED) from a comprehensive review of the academic literature, with a particular emphasis on changes since the original Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) . Studies of test efficacy and/or performance are influenced by the fact that subjects have often been selected based on the same tests that are under scrutiny. Similarly, the performance of any “new” test may be compromised when the test is assessed in a population of DED patients who have been diagnosed using non-standardized criteria.

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Cochet-Bonnet or non-contact air-jet esthesiometers have been employed to evaluate ocular surface sensitivity. Loss of corneal sensation can give rise to severe corneal epithelial disorders such as neurotrophic keratopathy [332,333]. The palpebral conjunctival sensitivity appears to be more critical than corneal sensitivity when assessing DED . Corneal esthesiometry is weakly correlated to other DED tests, but increases with severity of the disease and has achieved a reported specificity of 96%, but a sensitivity of just 19% .

Fluorescein should be instilled at the outer canthus to avoid ocular surface damage (see Section 8/4.1 for instillation instructions), with the excess saline on the strip shaken off, or a reduced area fluorescein strip used . For optimal results, viewing should take place between 1 and 3 min after instillation . A positive finding has been reported to be a value < 10 s although in some studies the average in healthy middle aged patients is noted to be lower than this .


Administrators and advanced users can use the Custom mode interface to create customized experiments ranging from sample autolabeling and uptake, through data acquisition, gating, and data analysis, to the generation of print-ready results. Custom users and administrators have advanced access to MACSQuant Instrument and software settings. Administrators have additional permissions concerning setting user permissions and the management of Express and Custom mode users. Both administrator and Custom user features are discussed throughout this chapter. Read the instructions in the user manual chapter Warnings and precautions before operation of the instrument.

Cross‐linked hyaluronate is available as Gel‐One in a 30 mg/3mL solution in 3‐mL prefilled glass syrinces. Gel‐One (cross‐linked hyaluronate) is one 3/0 mL injection. Safety and effectiveness of a repeat treatment cycle have not been established.


Combinations of phosphate buffered saline (PBS) and the 4 HA types were used as control. Rheological measurements were performed on an Anton PaarMCR-302 rheometer. Amplitude sweep, frequency sweep and rotational measurements were performed and viscoelastic properties were evaluated. The rheological data were validated performing the tests in presence of Bovine Serum Albumin (BSA) up to ultra-physiological concentration (7 %). Primary osteoarthritic chondrocytes were cultured in-vitro with the HA and PRP blends in the culture medium for 1 week. Cell viability, proliferation and glycosaminoglycan (GAG) content were assessed. PRP addition to HA led to a decrease of viscoelastic shear moduli and increase of the cross-over point, due to a pure dilution effect. For viscosupplements with HA concentration below 1 % the viscoelasticity is mostly lost. Results were validated also in presence of proteins, which in synovial fluid were more abundant than HA. Chondrocytes proliferated overtime in all different culture conditions. The proliferation rate was higher in chondrocytes cultured in the media containing PRP compared to the cultures with different HA alone. GAG content was significantly higher in chondrocytes cultured in PRP and HL blend.

Specific examination procedures for impression cytology are described elsewhere . For analyzing conjunctival impression cytology, several squamous metaplasia grading systems based on qualitative or quantitative cytological criteria are applied. The best-known methods include the systems by Nelson , Tseng , and Blades . Among them, the Nelson classification system, considering the density, morphology, cytoplasmic staining affinity and nucleus/cytoplasm ratio of conjunctival epithelial and goblet cells, remains widely used .