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The first excerpt below from the TFOS DEWS II Management and Therapy Report outlines a pretty simple equation:
Is it too much to ask that some more doctors step up to get the actual effects of moisture chambers on the tear film better documented? We all know these things are helping severe dry eye patients. Why not document the specifics of what we already believe to be true, so that that knowledge can seep out of specialty practice and into mainstream ophthalmology and
optometry? TFOS DEWS II - Management and Therapy Report
References in these two excerpts:
[43] She Y, Li J, Xiao B, Lu H, Liu H, Simmons PA, et al. Evaluation of a novel artificial tear in the prevention and treatment of dry eye in an animal model. J Ocul Pharmacol Ther 2015;31(9):525–530.
[307] Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 2010;(9):CD006775.
[314] Savar DE. A new approach to ocular moisture chambers. J Pediatr Ophthalmol Strabismus 1978 Jan-Feb;15(1):51–53.
[315] Gresset J, Simonet P, Gordon D. Combination of a side shield with an ocular moisture chamber. Am J Optom Physiol Opt 1984;61(9):610–612.
[316] Shen G, Qi Q, Ma X. Effect of Moisture Chamber Spectacles on Tear Functions in Dry Eye Disease. Optom Vis Sci 2016;93(2):158–164.
[317] Craig J, Chan E, Ea L, Kam C, Lu Y, Misra S. Dry eye relief for VDU users from a USB-desktop humidifier. Contact Lens Anter Eye 2012;35:28. e-abstract.
[931] McCulley JP, Uchiyama E, Aronowicz JD, Butovich IA. Impact of evaporation on aqueous tear loss. Trans Am Ophthalmol Soc 2006;104:121–128.
[932] Abusharha AA, Pearce EI. The effect of low humidity on the human tear film. Cornea 2013;32(4):429–434.
[933] Alex A, Edwards A, Hays JD, Kerkstra M, Shih A, de Paiva CS, et al. Factors predicting the ocular surface response to desiccating environmental stress. Invest Ophthalmol Vis Sci 2013;54:3325–3332.
[934] López-Miguel A, Tesón M, Martín-Montañez V, Enríquez-de-Salamanca A, Stern ME, Calonge M, et al. Dry eye exacerbation in patients exposed to desiccating stress under controlled environmental conditions. Am J Ophthalmol 2014;157(4):788–798. e2.
[935] Lopez-Miguel A, Teson M, Martin-Montanez V, Enriquez-de-Salamanca A, Stern ME, Gonzalez-Garcia MJ, et al. Clinical and Molecular Inflammatory Response in Sjogren Syndrome-Associated Dry Eye Patients Under Desiccating Stress. Am J Ophthalmol 2016;161. 133-41 e1–2.
[936] Oh HJ, Li Z, Park SH, Yoon KC. Effect of hypotonic 0.18% sodium hyaluronate eyedrops on inflammation of the ocular surface in experimental dry eye. J Ocul Pharmacol Ther 2014;30(7):533–542.
[937] Hill-Bator A, Misiuk-Hoj?o M, Marycz K, Grzesiak J. Trehalose-based eye drops preserve viability and functionality of cultured human corneal epithelial cells during desiccation. Biomed Res Int 2014;2014:292139.
[938] Moore QL, De Paiva CS, Pflugfelder SC. Effects of Dry Eye Therapies on Environmentally Induced Ocular Surface Disease. Am J Ophthalmol 2015;160(1):135–142. e1.
[939] Dohlman TH, Chauhan SK, Kodati S, Hua J, Chen Y, Omoto M, et al. The CCR6/CCL20 axis mediates Th17 cell migration to the ocular surface in dry eye disease. Invest Ophthalmol Vis Sci 2013;54(6):4081–4091.
[940] Goyal S, Chauhan SK, Zhang Q, Dana R. Amelioration of murine dry eye disease by topical antagonist to chemokine receptor 2. Arch Ophthalmol 2009;127(7):882–887.
[941] Urashima Hiroki, Takeji Yasuhiro, Okamoto Takashi, Fujisawa Shigeki, Shinohara Hisashi. Rebamipide Increases Mucin-Like Substance Contents and Periodic Acid Schiff Reagent-Positive Cells Density in Normal Rabbits. J Ocul Pharmacol Ther 2012;28(3):264–270.
[942] Nakamura S, Shibuya M, Nakashima H, Imagawa T, Uehara M, Tsubota K. D-beta-hydroxybutyrate protects against corneal epithelial disorders in a rat dry eye model with jogging board. Invest Ophthalmol Vis Sci 2005;46:2379–2387.
[943] Hirayama M, Murat D, Liu Y, Kojima T, Kawakita T, Tsubota K. Efficacy of a novel moist cool air device in office workers with dry eye disease. Acta Ophthalmol 2013;91(8):756–762.
[944] Willis RM, Folberg R, Krachmer JH, Holland EJ. The treatment of aqueous-deficient dry eye with removable punctal plugs. A clinical and impression-cytologic study. Ophthalmology 1987;94(5):514–518.
[945] Tsubota K, Yamada M, Urayama K. Spectacle side panels and moist inserts for the treatment of dry-eye patients. Cornea 1994;13(3):197–201.
[946] Yee RW, Sperling HG, Kattek A, Paukert MT, Dawson K, Garcia M, et al. Isolation of the ocular surface to treat dysfunctional tear syndrome associated with computer use. Ocul Surf 2007;5(4):308–315.
[947] Wakamatsu TH, Dogru M, Tsubota K. Tearful relations: oxidative stress, inflammation and eye diseases. Arq Bras Oftalmol 2008 Nov-Dec;71(6 Suppl):72–79.
[948] Satici A, Bitiren M, Ozardali I, Vural H, Kilic A, Guzey M. The effects of chronic smoking on the ocular surface and tear characteristics: a clinical, histological and biochemical study. Acta Ophthalmol Scand 2003;81(6):583–587.
[949] Altinors DD, Akça S, Akova YA, Bilezikçi B, Goto E, Dogru M, et al. Smoking associated with damage to the lipid layer of the ocular surface. Am J Ophthalmol 2006;141(6):1016–1021.
[950] Thomas J, Jacob GP, Abraham L, Noushad B. The effect of smoking on the ocular surface and the precorneal tear film. Australas Med J 2012;5(4):221–226.
[951] Matsumoto Y, Dogru M, Goto E, Sasaki Y, Inoue H, Saito I, et al. Alterations of the tear film and ocular surface health in chronic smokers. Eye (Lond) 2008;22(7):961–968.
[952] Rummenie VT, Matsumoto Y, Dogru M, Wang Y, Hu Y, Ward SK, et al. Tear cytokine and ocular surface alterations following brief passive cigarette smoke exposure. Cytokine 2008;43(2):200–208.
- Eyes are the most exposed (therefore vulnerable) mucous-covered part of the body.
- Low humidity, air movement and temperature extremes cause tear instability and evaporation.
- ...which causes dry eye where it doesn't exist, and make it worse where it does.
- ...which leads to a "cascade of events" including inflammation and changes in the MGs.
- And, there's LOTS of things that can be done both for prevent and for treatment
Is it too much to ask that some more doctors step up to get the actual effects of moisture chambers on the tear film better documented? We all know these things are helping severe dry eye patients. Why not document the specifics of what we already believe to be true, so that that knowledge can seep out of specialty practice and into mainstream ophthalmology and
optometry? TFOS DEWS II - Management and Therapy Report
7.4 Desiccating conditions and environmental pollutants
The ocular surface is the most environmentally exposed mucosal surface of the body, encountering challenges such as wind exposure, low relative humidity, temperature extremes, UV radiation, irritants, pollutants and tobacco smoke. Exposure to adverse ambient conditions such as low humidity and/or increased/decreased air temperature and/or air movement, leads to increased tear instability and evaporation [931]. These conditions promote the development of dry eye symptoms in normal individuals and also worsen symptoms and signs in those with DED [932–935]. Chronic dryness of the ocular surface results in a downstream cascade of events that promote inflammation, epithelial apoptosis, loss of goblet cells and changes in the meibomian glands. Studies have demonstrated the efficacy of certain treatments in response to unfavorable environmental conditions. These include the use of artificial tears [43,936,937], medications that suppress inflammatory responses [584,842,938–940], drugs that induce mucus secretion [941], and drugs that decrease apoptosis [942].
While avoiding exposure to adverse conditions that can increase tear instability and evaporation is the initial tactic, creating conditions that mimic an adequate environment for the ocular surface is also a valid approach. These include the use of humidifiers [317,943] and retention of tear fluid using moisture chamber spectacles, contact lenses and punctal plugs [307,944–946].
Increased air pollution is associated with dry eye [947] and factors such as cigarette smoking may result in a dysfunctional tear film [948–950]. Tobacco smoke contains many oxidizing and toxic substances, exposing inhalers to an enormous free radical load. Matsumoto et al. confirmed the deleterious effect of chronic cumulative tobacco smoke exposure on the tear film, resulting in an increase in tear hexanoyl-lysine levels, an oxidative stress marker for lipid peroxidation [951]. Similar findings were observed by Rummenie et al. following passive cigarette smoke exposure [952]. The adverse effects of passive tobacco smoke on the tear film is evidenced by an increase in tear inflammatory cytokines, lipid peroxidation products and a decrease in mucosal defense, resulting in instability and damage to the ocular surface epithelia [948,951]. Inhibition of the oxidative stress therapeutically might act to “break the cycle” of cytotoxicity, inflammation and cell death.
While avoiding exposure to adverse conditions that can increase tear instability and evaporation is the initial tactic, creating conditions that mimic an adequate environment for the ocular surface is also a valid approach. These include the use of humidifiers [317,943] and retention of tear fluid using moisture chamber spectacles, contact lenses and punctal plugs [307,944–946].
Increased air pollution is associated with dry eye [947] and factors such as cigarette smoking may result in a dysfunctional tear film [948–950]. Tobacco smoke contains many oxidizing and toxic substances, exposing inhalers to an enormous free radical load. Matsumoto et al. confirmed the deleterious effect of chronic cumulative tobacco smoke exposure on the tear film, resulting in an increase in tear hexanoyl-lysine levels, an oxidative stress marker for lipid peroxidation [951]. Similar findings were observed by Rummenie et al. following passive cigarette smoke exposure [952]. The adverse effects of passive tobacco smoke on the tear film is evidenced by an increase in tear inflammatory cytokines, lipid peroxidation products and a decrease in mucosal defense, resulting in instability and damage to the ocular surface epithelia [948,951]. Inhibition of the oxidative stress therapeutically might act to “break the cycle” of cytotoxicity, inflammation and cell death.
2.2.2 Moisture chamber spectacles and humidifiers
Moisture chamber spectacles are eyeglasses specially designed to slow evaporation of the tears, by providing a humid environment and minimizing airflow over the ocular surface. A number of such devices are available. While the clinical efficacy of moisture chamber spectacles has been reported in case reports [314,315], to date, no high level studies have investigated the therapeutic value of these devices, but it does appear that they can prove to be a potential adjunct to prescribed treatment, especially in adverse environments [316].
Locally placed humidifying devices have also been proposed to enhance humidity or local air quality. However, only one controlled study lends support to their effectiveness in the management of dry eye thus far [317].
Moisture chamber spectacles are eyeglasses specially designed to slow evaporation of the tears, by providing a humid environment and minimizing airflow over the ocular surface. A number of such devices are available. While the clinical efficacy of moisture chamber spectacles has been reported in case reports [314,315], to date, no high level studies have investigated the therapeutic value of these devices, but it does appear that they can prove to be a potential adjunct to prescribed treatment, especially in adverse environments [316].
Locally placed humidifying devices have also been proposed to enhance humidity or local air quality. However, only one controlled study lends support to their effectiveness in the management of dry eye thus far [317].
[43] She Y, Li J, Xiao B, Lu H, Liu H, Simmons PA, et al. Evaluation of a novel artificial tear in the prevention and treatment of dry eye in an animal model. J Ocul Pharmacol Ther 2015;31(9):525–530.
[307] Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 2010;(9):CD006775.
[314] Savar DE. A new approach to ocular moisture chambers. J Pediatr Ophthalmol Strabismus 1978 Jan-Feb;15(1):51–53.
[315] Gresset J, Simonet P, Gordon D. Combination of a side shield with an ocular moisture chamber. Am J Optom Physiol Opt 1984;61(9):610–612.
[316] Shen G, Qi Q, Ma X. Effect of Moisture Chamber Spectacles on Tear Functions in Dry Eye Disease. Optom Vis Sci 2016;93(2):158–164.
[317] Craig J, Chan E, Ea L, Kam C, Lu Y, Misra S. Dry eye relief for VDU users from a USB-desktop humidifier. Contact Lens Anter Eye 2012;35:28. e-abstract.
[931] McCulley JP, Uchiyama E, Aronowicz JD, Butovich IA. Impact of evaporation on aqueous tear loss. Trans Am Ophthalmol Soc 2006;104:121–128.
[932] Abusharha AA, Pearce EI. The effect of low humidity on the human tear film. Cornea 2013;32(4):429–434.
[933] Alex A, Edwards A, Hays JD, Kerkstra M, Shih A, de Paiva CS, et al. Factors predicting the ocular surface response to desiccating environmental stress. Invest Ophthalmol Vis Sci 2013;54:3325–3332.
[934] López-Miguel A, Tesón M, Martín-Montañez V, Enríquez-de-Salamanca A, Stern ME, Calonge M, et al. Dry eye exacerbation in patients exposed to desiccating stress under controlled environmental conditions. Am J Ophthalmol 2014;157(4):788–798. e2.
[935] Lopez-Miguel A, Teson M, Martin-Montanez V, Enriquez-de-Salamanca A, Stern ME, Gonzalez-Garcia MJ, et al. Clinical and Molecular Inflammatory Response in Sjogren Syndrome-Associated Dry Eye Patients Under Desiccating Stress. Am J Ophthalmol 2016;161. 133-41 e1–2.
[936] Oh HJ, Li Z, Park SH, Yoon KC. Effect of hypotonic 0.18% sodium hyaluronate eyedrops on inflammation of the ocular surface in experimental dry eye. J Ocul Pharmacol Ther 2014;30(7):533–542.
[937] Hill-Bator A, Misiuk-Hoj?o M, Marycz K, Grzesiak J. Trehalose-based eye drops preserve viability and functionality of cultured human corneal epithelial cells during desiccation. Biomed Res Int 2014;2014:292139.
[938] Moore QL, De Paiva CS, Pflugfelder SC. Effects of Dry Eye Therapies on Environmentally Induced Ocular Surface Disease. Am J Ophthalmol 2015;160(1):135–142. e1.
[939] Dohlman TH, Chauhan SK, Kodati S, Hua J, Chen Y, Omoto M, et al. The CCR6/CCL20 axis mediates Th17 cell migration to the ocular surface in dry eye disease. Invest Ophthalmol Vis Sci 2013;54(6):4081–4091.
[940] Goyal S, Chauhan SK, Zhang Q, Dana R. Amelioration of murine dry eye disease by topical antagonist to chemokine receptor 2. Arch Ophthalmol 2009;127(7):882–887.
[941] Urashima Hiroki, Takeji Yasuhiro, Okamoto Takashi, Fujisawa Shigeki, Shinohara Hisashi. Rebamipide Increases Mucin-Like Substance Contents and Periodic Acid Schiff Reagent-Positive Cells Density in Normal Rabbits. J Ocul Pharmacol Ther 2012;28(3):264–270.
[942] Nakamura S, Shibuya M, Nakashima H, Imagawa T, Uehara M, Tsubota K. D-beta-hydroxybutyrate protects against corneal epithelial disorders in a rat dry eye model with jogging board. Invest Ophthalmol Vis Sci 2005;46:2379–2387.
[943] Hirayama M, Murat D, Liu Y, Kojima T, Kawakita T, Tsubota K. Efficacy of a novel moist cool air device in office workers with dry eye disease. Acta Ophthalmol 2013;91(8):756–762.
[944] Willis RM, Folberg R, Krachmer JH, Holland EJ. The treatment of aqueous-deficient dry eye with removable punctal plugs. A clinical and impression-cytologic study. Ophthalmology 1987;94(5):514–518.
[945] Tsubota K, Yamada M, Urayama K. Spectacle side panels and moist inserts for the treatment of dry-eye patients. Cornea 1994;13(3):197–201.
[946] Yee RW, Sperling HG, Kattek A, Paukert MT, Dawson K, Garcia M, et al. Isolation of the ocular surface to treat dysfunctional tear syndrome associated with computer use. Ocul Surf 2007;5(4):308–315.
[947] Wakamatsu TH, Dogru M, Tsubota K. Tearful relations: oxidative stress, inflammation and eye diseases. Arq Bras Oftalmol 2008 Nov-Dec;71(6 Suppl):72–79.
[948] Satici A, Bitiren M, Ozardali I, Vural H, Kilic A, Guzey M. The effects of chronic smoking on the ocular surface and tear characteristics: a clinical, histological and biochemical study. Acta Ophthalmol Scand 2003;81(6):583–587.
[949] Altinors DD, Akça S, Akova YA, Bilezikçi B, Goto E, Dogru M, et al. Smoking associated with damage to the lipid layer of the ocular surface. Am J Ophthalmol 2006;141(6):1016–1021.
[950] Thomas J, Jacob GP, Abraham L, Noushad B. The effect of smoking on the ocular surface and the precorneal tear film. Australas Med J 2012;5(4):221–226.
[951] Matsumoto Y, Dogru M, Goto E, Sasaki Y, Inoue H, Saito I, et al. Alterations of the tear film and ocular surface health in chronic smokers. Eye (Lond) 2008;22(7):961–968.
[952] Rummenie VT, Matsumoto Y, Dogru M, Wang Y, Hu Y, Ward SK, et al. Tear cytokine and ocular surface alterations following brief passive cigarette smoke exposure. Cytokine 2008;43(2):200–208.