TFOS DEWS II Definition and Classification Report

The goals of the TFOS DEWS II Definition and Classification Subcommittee were to create an evidence-based definition and a contemporary classification system for dry eye disease (DED). The new definition recognizes the multifactorial nature of dry eye as a disease where loss of homeostasis of the tear film is the central pathophysiological concept. Ocular symptoms, as a broader term that encompasses reports of discomfort or visual disturbance, feature in the definition and the key etiologies of tear film instability, hyperosmolarity, and ocular surface inflammation and damage were determined to be important for inclusion in the definition. In the light of new data, neurosensory abnormalities were also included in the definition for the first time. In the classification of DED, recent evidence supports a scheme based on the pathophysiology where aqueous deficient and evaporative dry eye exist as a continuum, such that elements of each are considered in diagnosis and management. Central to the scheme is a positive diagnosis of DED with signs and symptoms, and this is directed towards management to restore homeostasis. The scheme also allows consideration of various related manifestations, such as non-obvious disease involving ocular surface signs without related symptoms, including neurotrophic conditions where dysfunctional sensation exists, and cases where symptoms exist without demonstrable ocular surface signs, including neuropathic pain. This approach is not intended to override clinical assessment and judgment but should prove helpful in guiding clinical management and research.     

Physical growth and endocrinal disorders during pubertal maturation in girls with epilepsy

PURPOSE: This study investigated the effect of epilepsy and/or antiepileptic drugs (AEDs) on the physical growth, pubertal development, and androgenic status of girls with epilepsy between ages 8 and 18 years. METHODS: Sixty-six female patients with epilepsy, their mean ages 13.47 +/- 3.5 years, were included. Anthropometric measurements, staging of pubertal maturation, and clinical manifestations of hyperandrogenism were assessed, as well as measurement of serum levels of testosterone, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), and free androgen index (FAI). Of the included patients, 44 had transabdominal ultrasonic examination of the ovaries and fasting serum insulin levels were measured. Forty healthy age-matched females served as a control group. RESULTS: Patients showed reduced mean height percentile compared with controls (z = 2.07; p = 0.04), which was negatively correlated with the duration of their epilepsy. Patients showed increased frequency of obesity, especially postpubertal girls taking valproate (VPA; 67%), who also showed higher insulin levels (t = 8.01; p = 0.0003). Patients showed increased frequency of clinical hyperandrogenemia in the different stages of puberty. High levels of testosterone and DHEAS were found in female patients with epilepsy, especially pubertal and postpubertal girls. Hyperandrogenism (clinical and/or laboratory) was most affected by the types of AEDs, with higher incidence in patients taking VPA compared with those taking enzyme-inducing AEDs (chi2= 9.16; p = 0.01). Eighteen percent of the patients were diagnosed as having polycystic ovary syndrome (PCOS). No difference was found in the types of seizures, degree of seizure control, type of AEDs, or insulin levels between patients with and those without PCOS. CONCLUSIONS: Longer duration of the disease has a negative impact on the stature of female patients with epilepsy. Postpubertal girls taking VPA are more liable to obesity, which is associated with increased incidence of hyperinsulinemia. Clinical and/or laboratory evidence of hyperandrogenism is seen at a high frequency in patients, especially with the use of VPA. Furthermore, female patients with epilepsy especially in the postpubertal stage of sexual maturation, have a high prevalence of PCOS, independent of the type of AED or the characteristics of the epilepsy disorder.     

The dangers of distilled water in contact lens maintenance

The reports of serious corneal infection associated with hydrogel lens wear prompted us to explore the level of sterility of the distilled water used by lens wearers in our practice. Fifty patients supplied samples of their partially-used distilled water for testing. Of the samples, 12% were found to be contaminated. Five samples of previously unopened distilled water were tested and no growth was found. We recommend that patients do not use distilled water for the care of hydrogel contact lenses. Rather, sterile unit dose or multi-dose (aerosol) nonpreserved, or preserved salines can be used.     

Corneal staining after instillation of topical anesthetic (SSII)

The ocular surface of 74 subjects was assessed with the biomicroscope after sequential instillations of fluorescein (SSI) and again after a single instillation of Ophthetic that was followed by sequential instillations of fluorescein (SSII). Twenty-six eyes (17.6%) stained after SSI and 89 eyes (60%) stained after SSII. The use of Ophthetic seems to enhance the nonuniform penetration of fluorescein into the epithelium in specific regions of the cornea of some subjects. The clinical significance of this finding is unknown.     

Visual field loss with colored hydrogel lenses

The visual fields of 10 healthy myopic patients were compared using hydrogel lenses with a clear pupil and an opaque colored portion covering the iris and clear hydrogel lenses. Significant (greater than 10 degrees) field loss was found in all cases when the midperipherally colored lenses were worn. Patients interested in these lenses should be advised of this slight reduction of peripheral vision before fitting.