Publications by authors named "Jennifer P Craig"

112 Publications

Demographic and lifestyle risk factors of dry eye disease subtypes: A cross-sectional study.

Ocul Surf 2021 May 15;21:58-63. Epub 2021 May 15.

Optometry and Vision Sciences, College of Health and Life Sciences, Aston University, Birmingham, UK; Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To evaluate demographic and lifestyle factors associated with aqueous deficient and evaporative dry eye disease.

Methods: A total of 1125 general public visitors (707 females, mean ± SD age, 33 ± 21, range 5-90 years) at the Royal Society Summer Science Exhibition were recruited in a cross-sectional study. A demographic and lifestyle factor questionnaire was administered, and dry eye symptomology (DEQ-5 score), ocular surface characteristics (conjunctival hyperaemia, and infrared meibography), and tear film parameters (tear meniscus height, non-invasive breakup time, and lipid layer grade) were evaluated for the left eye of each participant within a single session. The diagnostic criteria for dry eye disease subtypes were adapted from the rapid non-invasive dry eye assessment algorithm.

Results: Overall, 428 (38%) participants fulfilled the diagnostic criteria for dry eye disease, 161 (14%) with aqueous deficient dry eye disease, and 339 (30%) with evaporative dry eye disease. Multivariate logistic regression demonstrated that advancing age, female sex, reduced sleep duration, higher psychological stress, and poorer self-perceived health status were independently associated with aqueous deficient dry eye disease (all p < 0.05). Significant risk factors for evaporative dry eye disease included advancing age, East and South Asian ethnicity, contact lens wear, increased digital device screen exposure, higher psychological stress, and poorer self-perceived health status (all p < 0.05).

Conclusions: Both subtypes of dry eye disease were associated with several unique and shared demographic and lifestyle factors. The findings of this study could inform future research design investigating the utility of targeted screening and risk factor modification for the prevention and management of dry eye disease.
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http://dx.doi.org/10.1016/j.jtos.2021.05.001DOI Listing
May 2021

Clinical practice patterns in the management of dry eye disease: A TFOS international survey.

Ocul Surf 2021 May 6;21:78-86. Epub 2021 May 6.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand.

Purpose: To examine clinical management and prescribing patterns for dry eye disease (DED), in relation to severity and subtype, by eye care practitioners across the globe.

Methods: An online, anonymous cross-sectional survey (on Qualtrics) translated into 14 languages was distributed to eye care practitioners across the globe. The survey included six questions around the management of DED, in relation to severity and subtype.

Result: The survey was completed by 1139 eyecare professionals (37% ophthalmologists and 58% optometrists) from 51 countries. Management varied significantly by continent and country (p < 0.01). The most commonly recommended management approaches, internationally, included general advice (87%), low (85%) and high (80%) viscosity-enhancing unpreserved lubricants and lid wipes/scrubs (81%). Some treatments were prescribed largely independently of severity (e.g. artificial tears and nutritional supplements) while oral antibiotics, punctal occlusion, topical anti-inflammatory/immunosuppressants, secretagogues, biologics, therapeutic contact lenses and surgical approaches were prescribed by more practitioners as severity increased. Essential fatty acids, lipid sprays/drops, lid hygiene, warm compresses, intense pulsed light therapy and antibiotics (topical or oral) were more commonly recommended for evaporative DED, while punctal occlusion, therapeutic contact lenses, secretagogues and biologics were more commonly recommended for aqueous deficient DED.

Conclusions: DED management differs across continents and countries. A wide range of management strategies are utilised at each severity level and between subtypes. The survey results enable clinicians to benchmark their practice to that of their peers, indicate where further research is required to optimise patient management and inform industry on how best to target product development.
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http://dx.doi.org/10.1016/j.jtos.2021.04.011DOI Listing
May 2021

Investigating the neuroPRotective effect of Oral Omega-3 Fatty acid Supplementation in type 1 diabetes (nPROOFS1): a randomised, placebo-controlled trial.

Diabetes 2021 May 5. Epub 2021 May 5.

Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Australia.

This randomised, double-masked, placebo-controlled trial (ACTRN12618000705280) evaluated the effects of oral omega-3 fatty acid supplementation on peripheral nerves in type 1 diabetes. Participants with type 1 diabetes were assigned (1:1) to omega-3 (fish oil; 1800 mg/day) or placebo (olive oil; 600 mg/day) supplements for 180 days. Primary outcome was change from baseline in central corneal nerve fibre length (CNFL) at day 180. Secondary outcomes included change in other corneal nerve parameters, corneal sensitivity, peripheral small and large nerve fibre function, and ocular surface measures. Efficacy was analysed following intention-to-treat. Safety assessments included diabetic retinopathy grade and adverse events.Between July 2017 and September 2019, 43 participants received omega-3 (n=21) or placebo (n=22) supplements. All participants, except for two assigned to placebo, completed the trial. At day 180, the estimated increase in CNFL in the omega-3 group, compared to placebo, was 2.70 mm/mm2 (95%CI: 1.64-3.75). The Omega-3 Index increased relative to placebo (3.3%; 95%CI: 2.4-4.2). There were no differences in most small or large nerve fibre functional parameters. Adverse events were similar between groups.In conclusion, this randomised controlled trial found that long-chain omega-3 supplements impart corneal neuroregenerative effects in type 1 diabetes, indicating a role in modulating peripheral nerve health.
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http://dx.doi.org/10.2337/db21-0136DOI Listing
May 2021

Patient-reported experience of dry eye management: An international multicentre survey.

Cont Lens Anterior Eye 2021 Apr 30:101450. Epub 2021 Apr 30.

Optometry and Vision Science, College of Health and Life Sciences, Aston University, Birmingham, UK. Electronic address:

Purpose: To explore the journey taken by patients in a range of different countries to manage their dry eye symptoms.

Method: Members of the general public who responded positively to the question "Do your eyes ever feel dry?" completed a questionnaire describing their demographics, the impact of their symptomology, the advice they have received and the management options they have tried. The Ocular Surface Disease Index (OSDI) questionnaire was also completed.

Results: A total of 916 individuals (Canada = 235, Mexico = 127, New Zealand = 157, Taiwan = 246, UK = 151) of similar age distribution (median 38 years, IQR: 27-50) completed the survey. The reported duration of symptoms was longest in Canada (median 4 years, range 2-10) and least in Taiwan (2 years, range 1-3; p < 0.001), and similar trends were observed for symptom severity (p = 0.001). However, there was no statistically significant difference between countries with respect to the impact of symptoms on quality of life (median 3/10; p = 0.08). Less than half of the individuals in any country had consulted with a health professional. About half had tried a treatment for their dry eye symptoms, with artificial tears being the most common treatment, followed by warm compresses, and both therapies were rated as reasonably effective (median 5-7/10).

Conclusion: Many people with dry eye symptoms are not consulting health care professionals who can confirm the diagnosis, exclude differential diagnoses, and offer a wide range of treatments targeted at the dry eye subtype.
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http://dx.doi.org/10.1016/j.clae.2021.101450DOI Listing
April 2021

Safety and efficacy of UV application for superficial infections in humans: A systematic review and meta-analysis.

Ocul Surf 2021 Mar 31. Epub 2021 Mar 31.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand. Electronic address:

Background: Ultraviolet (UV) light is naturally antimicrobial, but risks associated with UV overexposure have limited its clinical application. This systematic review evaluates the safety and efficacy of UV light treatment of superficial human infections.

Methods: MEDLINE, Embase, Cochrane CENTRAL, ANZCTR and US National Library of Medicine were searched (March 25, 2020). Clinical studies applying UV light (200-400 nm) for superficial infections and non-clinical studies evaluating the antimicrobial effects of UV light on human samples were included. Randomised controlled trials (RCTs) and non- RCTs were appraised using the Cochrane risk of bias and the ROBINS-I tools, respectively.

Results: Eleven RCTs, seven non-RCTs, 24 case studies, and 11 in vitro studies were included. Most clinical studies (34/42) evaluated UVA treatment for microbial keratitis (MK) using cross-linking (UVA-CXL) methods. Six clinical studies assessed UVC; one, UVB; and one, broadband UV for chronic skin infections. Pooled data analysis showed no difference in the time to wound resolution with UVA-CXL relative to standard treatment (mean difference [MD]: -18.20 [95% CI: -39.04 to 2.65] days; p = 0.09). Adverse event incidence was similar to control for UVA-CXL in MK (RR: 0.70 [95%CI: 0.32-1.79]; 5 RCTs) and UVC in skin infections (RR: 0.63 [95%CI: 0.25-1.54]; 2 RCTs).

Conclusion: Alone or as an adjunct to standard therapy, UV light shows promise as a safe and effective treatment for a wide range of infections. Applications of UV light as an anti-infective agent are deserving of further evaluation, especially in the context of growing antibiotic resistance.

Registration: PROSPERO registration number CRD42020176510.
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http://dx.doi.org/10.1016/j.jtos.2021.03.002DOI Listing
March 2021

CLEAR - Anatomy and physiology of the anterior eye.

Cont Lens Anterior Eye 2021 Apr 25;44(2):132-156. Epub 2021 Mar 25.

School of Optometry, Aston University, Birmingham, UK; Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand.

A key element of contact lens practice involves clinical evaluation of anterior eye health, including the cornea and limbus, conjunctiva and sclera, eyelids and eyelashes, lacrimal system and tear film. This report reviews the fundamental anatomy and physiology of these structures, including the vascular supply, venous drainage, lymphatic drainage, sensory innervation, physiology and function. This is the foundation for considering the potential interactions with, and effects of, contact lens wear on the anterior eye. This information is not consistently published as academic research and this report provides a synthesis from all available sources. With respect to terminology, the report aims to promote the consistent use of nomenclature in the field, and generally adopts anatomical terms recommended by the Federative Committee for Anatomical Terminology. Techniques for the examination of the ocular surface are also discussed.
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http://dx.doi.org/10.1016/j.clae.2021.02.009DOI Listing
April 2021

Association between dry eye disease, self-perceived health status, and self-reported psychological stress burden.

Clin Exp Optom 2021 Mar 3:1-6. Epub 2021 Mar 3.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

: Dry eye disease is a common chronic ocular condition, which is acknowledged to have adverse impacts on quality of life and work productivity.: The wide-reaching impacts of dry eye disease on mental health and quality of life have received growing attention in recent years. The purpose of this study was therefore to investigate the relationship between dry eye disease, self-perceived health status, and self-reported psychological stress burden.: Three hundred and twelve community residents (178 females, 134 males; mean ± SD age, 38 ± 21 years) with no major systemic, ophthalmic, or psychiatric conditions (other than dry eye disease), were recruited in a cross-sectional study. Self-perceived health status and self-reported psychological stress burden were assessed, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the Tear Film and Ocular Surface Society Dry Eye Workshop II reports.: Multivariate regression analysis, adjusted for age, sex, ethnicity, and contact lens wear, demonstrated that improved self-perceived health status was associated with decreased odds of dry eye disease, aqueous tear deficiency and meibomian gland dysfunction (all p < 0.05). Increased self-reported psychological stress burden was positively associated with dry eye disease, aqueous tear deficiency and meibomian gland dysfunction (all p ≤ 0.01).: Dry eye disease is associated with poorer self-perceived health status and greater self-reported psychological stress burden. The findings of this study highlight the wide-reaching impacts of dry eye disease, and the importance of minimising the impacts of the condition with optimised management and actioning inter-disciplinary referral for affected patients where necessary.
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http://dx.doi.org/10.1080/08164622.2021.1887580DOI Listing
March 2021

Effect of therapeutic UVC on corneal DNA: Safety assessment for potential keratitis treatment.

Ocul Surf 2021 Apr 19;20:130-138. Epub 2021 Feb 19.

Ocular Surface Laboratory, Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: Antimicrobial ultraviolet C (UVC) has proven efficacy in vitro against keratitis isolates and has potential to treat corneal infection if safety can be confirmed.

Method: Safety of 265 nm, 1.93 mW/cm intensity UVC (15-300 s exposures) was investigated in vitro via cyclobutane pyrimidine dimer (CPD) formation in DNA of human cultured corneal epithelial cells; ex vivo, by evaluating UVC transmissibility as a function of porcine corneal thickness; and in vivo, by evaluating CPD induction in the mouse cornea following UVC exposure.

Results: A single exposure of 15 s UVC did not induce significant CPD formation (0.92 ± 1.45%) in vitro relative to untreated control (p = 0.93) whereas 300 s exposure caused extensive CPD formation (86.8 ± 13.73%; p < 0.0001). Cumulative exposure to 15 s UVC daily for 3 days induced more CPD (14.6 ± 8.2%) than a single equivalent 45 s exposure (8.3 ± 4.0%) (p < 0.001) but levels returned to baseline within 72 h (p = 0.29), indicating highly efficient DNA repair. Ex vivo, UVC transmission decreased sharply with increasing corneal thickness, confirming UVC effects are limited to the superficial corneal layers. In vivo evaluations demonstrated no detectable CPD after three consecutive daily 15 s UVC exposures, whereas a single 300 s exposure induced extensive CPD formation in superficial corneal epithelium.

Conclusion: Up to three daily doses of 15 s UVC, in vivo, appear safe with respect to CPD formation. Ongoing research exploring UVC as a possible treatment for microbial keratitis is warranted.
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http://dx.doi.org/10.1016/j.jtos.2021.02.005DOI Listing
April 2021

Formulation Considerations for the Management of Dry Eye Disease.

Pharmaceutics 2021 Feb 3;13(2). Epub 2021 Feb 3.

Buchanan Ocular Therapeutics Unit, Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland 1142, New Zealand.

Dry eye disease (DED) is one of the most common ocular surface disorders characterised by a deficiency in quality and/or quantity of the tear fluid. Due to its multifactorial nature involving several inter-related underlying pathologies, it can rapidly accelerate to become a chronic refractory condition. Therefore, several therapeutic interventions are often simultaneously recommended to manage DED efficiently. Typically, artificial tear supplements are the first line of treatment, followed by topical application of medicated eyedrops. However, the bioavailability of topical eyedrops is generally low as the well-developed protective mechanisms of the eye ensure their rapid clearance from the precorneal space, thus limiting ocular penetration of the incorporated drug. Moreover, excipients commonly used in eyedrops can potentially exhibit ocular toxicity and further exacerbate the signs and symptoms of DED. Therefore, formulation development of topical eyedrops is rather challenging. This review highlights the challenges typically faced in eyedrop development, in particular, those intended for the management of DED. Firstly, various artificial tear supplements currently on the market, their mechanisms of action, as well as their application, are discussed. Furthermore, formulation strategies generally used to enhance ocular drug delivery, their advantages and limitations, as well as their application in commercially available DED eyedrops are described.
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http://dx.doi.org/10.3390/pharmaceutics13020207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7913303PMC
February 2021

Modifiable lifestyle risk factors for dry eye disease.

Cont Lens Anterior Eye 2021 Jan 21:101409. Epub 2021 Jan 21.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand; Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom. Electronic address:

Purpose: To examine the association between modifiable lifestyle factors and dry eye disease.

Methods: Three hundred and twenty-two community residents (186 females, 136 males; mean ± SD age, 41 ± 22 years) with no major systemic or ophthalmic conditions (other than dry eye disease) were recruited in a cross-sectional study. A lifestyle factor questionnaire was administered, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports.

Results: A total of 111 (34 %) participants fulfilled the TFOS DEWS II diagnostic criteria for dry eye disease. Multivariate regression analysis demonstrated that advancing age, female sex, East Asian ethnicity, and increased digital screen exposure time were positive risk factors for dry eye disease (all p < 0.05), while increased caffeine consumption was a protective factor (p = 0.04).

Conclusions: Increased digital screen exposure time and reduced caffeine consumption were modifiable lifestyle factors associated with higher odds of dry eye disease. These findings might contribute to informing the design of future prospective research investigating the efficacy of preventative intervention and risk factor modification strategies.
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http://dx.doi.org/10.1016/j.clae.2021.01.004DOI Listing
January 2021

Developing evidence-based guidance for the treatment of dry eye disease with artificial tear supplements: A six-month multicentre, double-masked randomised controlled trial.

Ocul Surf 2021 Apr 2;20:62-69. Epub 2021 Jan 2.

Optometry and Vision Science Research Group, Aston University, Birmingham, UK.

Purpose: To assess the six-month therapeutic profiles of lipid and non-lipid-based artificial tear supplements in managing dry eye disease (DED).

Methods: Ninety-nine participants fulfilling the TFOS DEWS II diagnostic criteria for DED (64% females; mean ± SD age, 44 ± 16 years) were enrolled in a prospective, multicentre, double-masked, parallel group, randomised controlled trial. Participants instilled lipid-based nanoemulsion drops or non-lipid-based aqueous drops for six months, at least four times daily. Symptomology, tear film and ocular surface characteristics were assessed at Days 0, 30, 60, 90, 120, 150 and 180.

Results: Sustained reductions in OSDI, DEQ-5, and SANDE symptom scores from baseline were observed from Day 30 onwards in both groups (all p < 0.05) and decreased superior lid wiper epitheliopathy grades from Day 60 onwards (all p ≤ 0.01). Improvements in non-invasive tear film breakup time, and sodium fluorescein and lissamine green staining scores followed from Day 120 onwards in both groups (all p < 0.05). Tear lipid layer grades increased from Day 90 onwards only with the lipid-based drops, and with significantly greater improvement in those with suboptimal lipid layer thickness at baseline (grade ≤3; p = 0.02). By Day 180, 19% of participants no longer fulfilled the diagnostic criteria for DED.

Conclusions: Over a six-month treatment period, improvements in dry eye symptomology preceded tear film and ocular surface changes with regular use of both lipid and non-lipid-based artificial tear supplements. Both formulations addressed most mild-to-moderate forms of aqueous deficient and evaporative DED, while evaporative cases benefitted preferentially from lipid-based supplementation. This represents a first step towards mapping DED therapeutic strategies according to disease subtype and severity.
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http://dx.doi.org/10.1016/j.jtos.2020.12.006DOI Listing
April 2021

Therapeutic potential of castor oil in managing blepharitis, meibomian gland dysfunction and dry eye.

Clin Exp Optom 2021 Apr 10;104(3):315-322. Epub 2021 Mar 10.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

The multifactorial pathogenesis and interrelationship of blepharitis, meibomian gland dysfunction and dry eye disease poses challenges to any therapeutic approach. Current treatments are mostly palliative, with success limited by perceived inefficacy and poor patient compliance. Castor oil, a natural derivative of the Ricinus communis plant, is widely used as an emollient in cosmetics and personal care products, drug delivery systems and wound dressings. Castor oil is deemed safe and tolerable, with strong anti-microbial, anti-inflammatory, anti-nociceptive, analgesic, antioxidant, wound healing and vaso-constrictive properties. Its main constituent, ricinoleic acid, has a bipolar molecular structure that promotes the formation of esters, amides and polymers. These can supplement deficient physiological tear film lipids, enabling enhanced lipid spreading characteristics and reducing aqueous tear evaporation. Studies reveal that castor oil applied topically to the ocular surface has a prolonged residence time, facilitating increased tear film lipid layer thickness, stability, improved ocular surface staining and symptoms. This review summarises the properties, current uses of, and therapeutic potential of castor oil in managing ocular surface disease. The biochemical, medicinal actions of castor oil are explored from the perspective of ocular surface pathology, and include microbial and demodectic over-colonisation, inflammatory and oxidative processes, as well as clinical signs and symptoms of dryness and discomfort.
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http://dx.doi.org/10.1111/cxo.13148DOI Listing
April 2021

Evaluating the diagnostic ability of two automated non-invasive tear film stability measurement techniques.

Cont Lens Anterior Eye 2020 Sep 10:101362. Epub 2020 Sep 10.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To evaluate the comparability, discriminative ability, and optimal thresholds for non-invasive tear film breakup time measurements obtained from the Oculus Keratograph 5M and Medmont E300 in detecting other signs and symptoms of dry eye disease, as defined by the TFOS DEWS II diagnostic criteria.

Methods: One hundred and thirty-four participants (53 male, 81 female), with a mean ± SD age of 48 ± 20 years, were recruited into a prospective, investigator-masked, diagnostic accuracy study. Dry eye symptomology, tear film parameters (including non-invasive Keratograph and Medmont breakup time), and ocular surface staining were evaluated in a single clinical session.

Results: Significant positive correlation was observed between the two automated instruments (p < 0.001), although non-invasive breakup time measurements obtained from the Medmont were significantly longer (p < 0.001), and demonstrated greater intra-subject and inter-subject variability (all p < 0.001). The areas under the ROC curves exceeded 0.65 for both instruments, and the discriminative abilities were comparable (p = 0.53). The Youden optimal diagnostic threshold for non-invasive tear film stability measurements obtained from the Keratograph was ≤8 seconds, and the optimal cut-off for breakup time measurements obtained from the Medmont was ≤14 seconds.

Conclusions: Despite significant positive correlation, breakup time measurements obtained from the Keratograph and Medmont were not directly interchangeable. Measurements from the Medmont were significantly longer and demonstrated greater intra-subject and inter-subject variability, although the two automated, non-invasive methods for assessing tear film stability exhibited comparable overall performance in diagnosing dry eye disease.
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http://dx.doi.org/10.1016/j.clae.2020.08.006DOI Listing
September 2020

Prophylactic action of lipid and non-lipid tear supplements in adverse environmental conditions: A randomised crossover trial.

Ocul Surf 2020 10 15;18(4):920-925. Epub 2020 Aug 15.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To evaluate the prophylactic benefits of lipid-based and non-lipid-based artificial tear lubricants, in dry eye disease, after adverse environmental exposure.

Methods: Twenty-eight participants with dry eye disease were recruited in a prospective, double-masked, randomised crossover trial. On separate days, participants were randomised to receive a single application of a lipid-containing tear supplement (Systane Complete) to one eye, and a non-lipid containing eye drop (Systane Ultra) to the contralateral eye. Participants were then exposed to a previously validated simulated adverse environment. Symptoms, non-invasive tear film breakup time, lipid layer grade, and tear meniscus height were assessed at three time points; baseline, following eye drop instillation, and after exposure to the adverse environment.

Results: Both treatments effected improvements in symptoms and non-invasive tear film stability following instillation (all p < 0.05), although an improvement in lipid layer quality was limited to the lipid-containing nano-emulsion tear supplement (p = 0.003). Although protective effects were conferred by both treatments following exposure to the simulated adverse environment, more favourable symptomology scores, non-invasive tear film stability, and lipid layer quality were observed in the lipid-containing tear supplement group (all p < 0.05). No significant changes were observed in tear meniscus height in both treatment groups (all p > 0.05).

Conclusions: Both the lipid and non-lipid-based artificial tear supplement demonstrated prophylactic benefits in a simulated adverse environment. However, the ability to preserve tear film quality and reduce dry eye symptomology was greater with the lipid-containing eye drop.

Trial Registration Number: ACTRN12619000361101.
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http://dx.doi.org/10.1016/j.jtos.2020.08.004DOI Listing
October 2020

Characterising the ocular surface and tear film in a population-based birth cohort of 45-year old New Zealand men and women.

Ocul Surf 2020 10 13;18(4):808-813. Epub 2020 Aug 13.

Department of Ophthalmology, University of Otago, Dunedin, New Zealand.

Purpose: To assess the prevalence of dry eye disease, aqueous tear deficiency, meibomian gland dysfunction, and asymptomatic ocular surface disease in a population-based cohort of 45-year-old New Zealand men and women.

Methods: This cross-sectional study of 885 participants (442 females, 443 males) was based on a population-representative birth cohort of individuals born between April 1 1972 and March 31 1973 in Dunedin, New Zealand (the Dunedin Multidisciplinary Health and Developmental Study). Participants were assessed at 45 years of age, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session. The diagnosis of dry eye disease was made according to the validated rapid non-invasive dry eye assessment algorithm.

Results: Clinical dry eye signs were present in 402 (45%) participants, of which 78 (9%) participants fulfilled the diagnostic criteria for dry eye disease, and 322 (37%) had asymptomatic ocular surface disease. Among participants with dry eye disease, 22 (2%) exhibited aqueous tear deficiency, and 65 (7%) had meibomian gland dysfunction. Females were more likely to be affected by dry eye disease, meibomian gland dysfunction, and asymptomatic ocular surface disease (all p < 0.05).

Conclusions: Clinical dry eye signs were present in almost half of this population-based cohort of 45-year-old New Zealanders, although only 9% of participants fulfilled the diagnostic criteria for dry eye disease. The high prevalence of asymptomatic ocular surface disease presents an opportunity for preventative public health intervention.
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http://dx.doi.org/10.1016/j.jtos.2020.08.005DOI Listing
October 2020

Two cases of episcleral tattooing presenting to the acute ophthalmic clinic.

N Z Med J 2020 07 31;133(1519):116-120. Epub 2020 Jul 31.

Associate Professor of Ophthalmology, The University of Auckland, Auckland.

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July 2020

Ageing and the natural history of dry eye disease: A prospective registry-based cross-sectional study.

Ocul Surf 2020 10 3;18(4):736-741. Epub 2020 Aug 3.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand. Electronic address:

Purpose: To investigate the impact of ageing on ocular surface parameters, and empirically determine optimal prognostic cut-off ages for clinical markers of dry eye disease, aqueous tear deficiency, and meibomian gland dysfunction.

Methods: A total of 1331 community residents (785 females, 546 males; mean ± SD age, 38 ± 19 years) were recruited in a prospective registry-based cross-sectional study. Dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports.

Results: Multivariate regression analysis demonstrated positive associations between ageing and clinical markers of dry eye disease (all p ≤ 0.001). The Youden-optimal prognostic cut-off ages for signs of meibomian gland dysfunction occurred during the third decade of life (24-29 years); the optimal predictive ages for lid wiper epitheliopathy, tear film instability, hyperosmolarity, and dry eye symptoms occurred during the fourth decade of life (31-38 years); while the optimal prognostic thresholds for signs of aqueous tear deficiency and ocular surface staining occurred in the fifth and sixth decades of life (46-52 years).

Conclusions: Advancing age is a significant risk factor for dry eye disease, which represents a growing public health concern with the ageing population worldwide. Signs of meibomian gland dysfunction appeared earlier in the natural history of disease progression, and the brief delay prior to the development of other clinical dry eye signs might represent a window of opportunity for preventative interventions in the young adult age group.
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http://dx.doi.org/10.1016/j.jtos.2020.07.003DOI Listing
October 2020

Ocular Demodex: a systematic review of the clinical literature.

Ophthalmic Physiol Opt 2020 07 21;40(4):389-432. Epub 2020 Jul 21.

Department of Optometry and Vision Sciences, The University of Melbourne, Melbourne, Australia.

Purpose: There is increasing clinical and research interest in the potential contribution of Demodex to ocular surface disease. The aim of this systematic review was to summarise and synthesise current clinical evidence relating to the aetiology, diagnosis and treatment of ocular Demodex.

Recent Findings: A comprehensive literature search was performed in OVID Medline, OVID Embase, and clinical trial registries, for studies published between 1990 and August 2019, examining Demodex on the ocular surface. The review included primary clinical research studies and systematic reviews of primary clinical research studies, where Demodex was considered in the context of the ocular surface and/or adnexa. Studies were categorised using the National Health and Medical Research Council evidence hierarchy. Risk of bias assessment was performed using validated tools for studies categorised as providing Level I or II evidence. A total of 87 studies were eligible for inclusion, including two systematic reviews. Most studies (60%) were observational, describing the prevalence of ocular Demodex in different clinical populations. There was a high degree of variability in the epidemiological data derived from cross-sectional aetiology studies. There was mostly consistent evidence to support an association between ocular Demodex and chronic blepharitis. Seven diagnostic test-accuracy studies were identified, which considered a range of techniques, including slit lamp examination for cylindrical eyelash collarettes and/or eyelash manipulation techniques, light microscopic evaluation of epilated eyelashes and in vivo confocal microscopy. There is currently no accepted gold-standard diagnostic method for ocular Demodex. For intervention studies, there was one systematic review, 11 published randomised trials, six trial registry entries, and nine case series. Despite a number of recent trials, the appropriate treatment regimen for ocular Demodex (including the optimal criteria and timing of an intervention) is not clearly established.

Conclusions: This comprehensive narrative synthesis has captured the landscape of clinical evidence relating to the prevalence, aetiology, diagnosis and treatment of ocular Demodex. There remain opportunities to enhance understanding of its role in ocular surface disease, best diagnostic approaches and optimal treatment protocols.
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http://dx.doi.org/10.1111/opo.12691DOI Listing
July 2020

TFOS European Ambassador meeting: Unmet needs and future scientific and clinical solutions for ocular surface diseases.

Ocul Surf 2020 10 3;18(4):936-962. Epub 2020 Jun 3.

Institute of Vision and Optics, University of Crete, and Department of Ophthalmology, University Hospital of Heraklion, Heraklion, Greece.

The mission of the Tear Film & Ocular Surface Society (TFOS) is to advance the research, literacy, and educational aspects of the scientific field of the tear film and ocular surface. Fundamental to fulfilling this mission is the TFOS Global Ambassador program. TFOS Ambassadors are dynamic and proactive experts, who help promote TFOS initiatives, such as presenting the conclusions and recommendations of the recent TFOS DEWS II™, throughout the world. They also identify unmet needs, and propose future clinical and scientific solutions, for management of ocular surface diseases in their countries. This meeting report addresses such needs and solutions for 25 European countries, as detailed in the TFOS European Ambassador meeting in Rome, Italy, in September 2019.
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http://dx.doi.org/10.1016/j.jtos.2020.05.006DOI Listing
October 2020

Randomized trial of topical periocular castor oil treatment for blepharitis.

Ocul Surf 2021 01 15;19:145-150. Epub 2020 May 15.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To evaluate the effects of topical castor oil application to the eyelids on ocular surface and tear film parameters in patients with blepharitis.

Methods: Twenty-six participants (14 females, 12 males; mean ± SD age, 38 ± 21 years) with clinical signs of blepharitis were enrolled in a prospective, investigator-masked, randomized, paired-eye trial. A 100% cold pressed castor oil formulation (Lotus Garden Botanicals, Biddeford, ME, USA) was applied to the eyelids of one eye (randomized), twice daily for 4 weeks. Ocular surface characteristics, symptoms, and tear film parameters were assessed at baseline and day 28.

Results: Baseline measurements did not differ between treated and control eyes (all p > 0.05). A significant reduction in OSDI symptomology score was observed following the four-week treatment period (p = 0.001). Clinical improvements in eyelid margin thickening, telangiectasia, eyelash matting, madarosis, cylindrical dandruff, and lid wiper epitheliopathy were limited to treated eyes (all p < 0.01), while greater decreases in staphylococcal and seborrheic eyelash crusting were observed in treated than control eyes (both p < 0.05). No adverse events were reported during the treatment period.

Conclusion: Topical castor oil application effected significant improvements in ocular surface signs and symptoms in patients with blepharitis. The favourable therapeutic profile would suggest that castor oil demonstrates promise as a potential treatment for blepharitis, and support the conduct of further efficacy trials with longer follow up.

Trial Registration Number: ACTRN12618000856213.
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http://dx.doi.org/10.1016/j.jtos.2020.05.007DOI Listing
January 2021

Oral medication prescribing by optometrists in New Zealand.

Clin Exp Optom 2021 Apr 10;104(3):425-427. Epub 2021 Mar 10.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/cxo.13089DOI Listing
April 2021

Omega-3 Fatty Acids and Eye Health: Opinions and Self-Reported Practice Behaviors of Optometrists in Australia and New Zealand.

Nutrients 2020 Apr 22;12(4). Epub 2020 Apr 22.

Department of Optometry and Vision Sciences, The University of Melbourne, Victoria 3053, Australia.

This study investigated optometrists' attitudes and self-reported practice behaviors towards omega-3 fatty acids for eye health, and knowledge and understanding of their potential risks and benefits. An anonymous online survey was distributed to optometrists in Australia and New Zealand. Questions included practitioner demographics and practice modality; self-reported practices and recommendations relating to diet, nutritional supplements, and omega-3 fatty acids for age-related macular degeneration (AMD) and dry eye disease (DED); and practitioner knowledge about omega-3 fatty acids. Of 206 included surveys, most respondents (79%) indicated recommending for their patients to consume omega-3 fatty acids to improve their eye health. Sixty-eight percent of respondents indicated recommending omega-3-rich foods for AMD management, while 62% indicated recommending omega-3 supplements. Most respondents (78%) indicated recommending omega-3-rich foods or supplements for DED. For DED, recommended omega-3 supplement dosages were (median [inter-quartile range, IQR]) 2000 mg [1000-2750 mg] per day. The main sources of information reported by respondents to guide their clinical decision making were continuing education articles and conferences. In conclusion, optometrists routinely make clinical recommendations about diet and omega-3 fatty acids. Future education could target improving optometrists' knowledge of differences in the evidence for whole-food versus supplement sources of omega-3 fatty acids in AMD. Further research is needed to address uncertainties in the evidence regarding optimal omega-3 dosage and formulation composition in DED.
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http://dx.doi.org/10.3390/nu12041179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230711PMC
April 2020

Systemic risk factors of dry eye disease subtypes: A New Zealand cross-sectional study.

Ocul Surf 2020 07 18;18(3):374-380. Epub 2020 Apr 18.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand; Optometry and Vision Science Research Group, School of Life and Health Sciences, Aston University, Birmingham, UK. Electronic address:

Purpose: To evaluate systemic risk factors of dry eye disease, aqueous tear deficiency, and meibomian gland dysfunction.

Methods: Three hundred and seventy-two community residents (222 females, 150 males; mean ± SD age, 39 ± 22 years) were recruited in a cross-sectional study. Past medical history, dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session. The diagnosis of dry eye disease, aqueous tear deficiency, and meibomian gland dysfunction were based on the global consensus recommendations of the Tear Film and Ocular Surface Society's Dry Eye Workshop II (TFOS DEWS II) and International Workshop on Meibomian Gland Dysfunction.

Results: Overall, 109 (29%) participants fulfilled the TFOS DEWS II criteria for dry eye disease, 42 (11%) had aqueous tear deficiency, and 95 (26%) had meibomian gland dysfunction. Multivariate logistic regression analysis demonstrated that systemic rheumatologic disease and antidepressant medication were independently associated with aqueous tear deficiency (both p < 0.05). Significant risk factors for meibomian gland dysfunction included age, East Asian ethnicity, migraine headaches, thyroid disease, and oral contraceptive therapy (all p ≤ 0.01).

Conclusions: Both etiological subtypes of dry eye disease were associated with a number of systemic risk factors. These findings would support routine systemic inquiry of dry eye disease and associated systemic conditions and medications, in order to facilitate opportunistic screening and timely inter-disciplinary referral where necessary.
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http://dx.doi.org/10.1016/j.jtos.2020.04.003DOI Listing
July 2020

Randomised double-masked placebo-controlled trial of the cumulative treatment efficacy profile of intense pulsed light therapy for meibomian gland dysfunction.

Ocul Surf 2020 04 30;18(2):286-297. Epub 2020 Jan 30.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To assess long-term cumulative treatment effects of intense pulsed light (IPL) therapy in meibomian gland dysfunction (MGD).

Methods: Eighty-seven symptomatic participants (58 female, mean ± SD age, 53 ± 16 years) with clinical signs of MGD were enrolled in a prospective, double-masked, parallel-group, randomised, placebo-controlled trial. Participants were randomised to receive either four or five homogeneously sequenced light pulses or placebo treatment to both eyes, (E-Eye Intense Regulated Pulsed Light, E-Swin, France). Visual acuity, dry eye symptomology, tear film parameters, and ocular surface characteristics were assessed immediately before treatment on days 0, 15, 45, 75, and four weeks after treatment course completion on day 105. Inflammatory and goblet cell function marker expression, and eyelid swab microbiology cultures were evaluated at baseline and day 105.

Results: Significant decreases in OSDI, SPEED, and SANDE symptomology scores, and meibomian gland capping, accompanied by increased tear film lipid layer thickness, and inhibited Corynebacterium macginleyi growth were observed in both treatment groups (all p < 0.05). Sustained clinical improvements occurred in both treatment groups from day 75, although significant changes from day 45, in lipid layer quality, meibomian gland capping, OSDI and SANDE symptomology, were limited to the five-flash group (all p < 0.05).

Conclusions: IPL therapy effected significant improvements in dry eye symptomology, tear film lipid layer thickness, and meibomian gland capping in MGD patients. Five-flash IPL treatment showed superior clinical efficacy to four-flash, and an initial course of at least four treatments is suggested to allow for establishment of sustained cumulative therapeutic benefits prior to evaluation of overall treatment efficacy.

Trial Registration Number: ACTRN12616000667415.
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http://dx.doi.org/10.1016/j.jtos.2020.01.003DOI Listing
April 2020

Cytomorphological assessment of the lid margin in relation to symptoms, contact lens wear and lid wiper epitheliopathy.

Ocul Surf 2020 04 7;18(2):214-220. Epub 2019 Dec 7.

Centre for Ocular Research & Education (CORE), School of Optometry and Vision Science, University of Waterloo, Canada.

Purpose: Lid wiper epitheliopathy (LWE) is insufficiently understood from a cytological perspective. This study explored the relationship between lid margin cytomorphology, LWE, contact lens wear, and lens-related symptoms.

Methods: Habitual, symptomatic (n = 20) and asymptomatic (n = 20) soft, rigid gas permeable (n = 18) and non-contact lens wearers (n = 19) were enrolled. LWE was graded using lissamine green and the Korb scale. Subjective symptoms were assessed using the Ocular Surface Disease Index and the Contact Lens Dryness Evaluation Questionnaire. Impression cytology samples obtained from the central upper and lower lid margins of both eyes stained histologically to highlight keratinization and imaged using high-resolution microscopy. A masked investigator digitally delimited and measured the average sagittal width of the lid wiper conjunctiva and mucocutaneous junction using ImageJ.

Results: The upper lid wiper conjunctiva measured 424 ± 171 μm, 404 ± 75, 667 ± 219 and 266 ± 64 in asymptomatic soft, symptomatic soft, rigid and non-contact lens wearers, respectively. The corresponding lower lid wiper conjunctivae measured 141 ± 57 μm, 232 ± 150, 519 ± 212 and 225 ± 102, which was significantly narrower than that of the upper eyelid in most cases (p < 0.05). Symptoms were not associated with lid margin changes; however, rigid lens wear and clinical LWE were associated with histologically enlarged lid wiper conjunctival areas and increased keratinization.

Conclusion: A novel, exploratory account of histological measures of LWE and cytomorphological change associated with contact lens wear suggests mechanical or frictional cellular insult is occurring at the lid wiper conjunctiva.
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http://dx.doi.org/10.1016/j.jtos.2019.12.001DOI Listing
April 2020

Improved Demodex diagnosis in the clinical setting using a novel in situ technique.

Cont Lens Anterior Eye 2020 08 3;43(4):345-349. Epub 2019 Dec 3.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address:

Purpose: To compare existing and novel diagnostic techniques for confirming ocular Demodex infestation and to recommend the most reliable method for routine use by eye care practitioners, based on yield and clinical applicability.

Methods: Fifteen participants with a prior Demodex blepharitis diagnosis or featuring typical cylindrical dandruff (CD) collarettes, and seven healthy controls were enrolled. Demodex presence was assessed using five techniques, applied consecutively, on a minimum of two different eyelashes on each eyelid of every participant, for each test, in situ: 1. using fine-point forceps and 25-40x biomicroscopy magnification, by eyelash rotation as proposed by Mastrota (ROT); 2. by removing cylindrical dandruff and exposing the eyelash insertion point at the lid margin (CDR); and 3. by laterally tensioning the eyelash (LET) following CDR. The typical appearance of cigar-shaped mite tails protruding from each assessed eyelash follicle was observed, and mite tails counted and averaged per participant for each assessment technique. 4. Lash epilation, and mite presence evaluated using bright-field microscopy at 10-40x magnification (EPI). 5. Finally, eyelash follicles were imaged using in vivo confocal microscopy (IVCM) and the images visually inspected for mite presence.

Results: In the Demodex group, the highest numbers of mites/eyelash were identified by LET (3.8 ± 1.4), versus CDR (2.4 ± 1.6) and ROT (1.1 ± 1.2), alone (all p < 0.002). An average of 1.0 ± 0.8 mites/lash was identified by EPI. IVCM failed to offer unequivocal evidence of Demodex presence even in confimed cases.

Conclusions: A novel technique for the clinical diagnosis and grading of Demodex in situ is described. By removing cylindrical dandruff and applying static, lateral tension to the eyelash without epilation, large numbers of mites are visible at the exposed eyelash follicle. The proposed method is convenient and clinically applicable, requiring only forceps and 25-40x biomicroscope magnification, and allowing rapid, efficient evaluation of large numbers of eyelashes.
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http://dx.doi.org/10.1016/j.clae.2019.11.009DOI Listing
August 2020

Epidemiologic Research in Dry Eye Disease and the Utility of Mobile Health Technology.

JAMA Ophthalmol 2020 01;138(1):69-70

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1001/jamaophthalmol.2019.4833DOI Listing
January 2020

Randomized masked trial of the clinical efficacy of MGO Manuka Honey microemulsion eye cream for the treatment of blepharitis.

Ocul Surf 2020 01 20;18(1):170-177. Epub 2019 Nov 20.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand.

Purpose: To assess the clinical efficacy of a novel MGO Manuka Honey microemulsion (MHME) eye cream for the management of blepharitis.

Methods: Fifty-three participants (32 females, 21 males; mean ± SD age, 60 ± 12 years) with clinical signs of blepharitis were enrolled in a prospective, investigator-masked, randomized, paired-eye trial. The MHME eye cream (Manuka Health New Zealand) was applied to the closed eyelids of one eye (randomized) overnight for 3 months. Visual acuity, ocular surface characteristics, symptoms and tear film parameters were assessed at baseline, day 30, and day 90. Eyelid swab microbiology cultures were evaluated at baseline and day 90.

Results: Baseline measurements did not differ between treated and control eyes (all p > 0.05). Significant reductions in SANDE and SPEED symptomology scores were detected in treated eyes on days 30 and 90 (all p < 0.05), while clinical improvements in non-invasive tear film breakup time, lipid layer thickness, and inferior lid wiper epitheliopathy were observed on day 90 (all p < 0.05). Following the 3-month treatment period, ocular Demodex, Corynebacterium macginleyi, Propionibacterium acnes, and Staphylococcus epidermidis load decreased significantly in treated eyes (all p ≤ 0.001). There were no changes in visual acuity during the 90-day period (all p > 0.05), and no major adverse events were reported.

Conclusion: Topical overnight application of the MHME eye cream effected significant improvements in ocular surface symptomology, tear film stability and lipid layer thickness, and reduced lid margin staining, ocular Demodex and bacterial load. The favourable clinical efficacy and tolerability profile suggests promise for the MHME eye cream as a treatment for blepharitis management.

Trial Registration Number: ACTRN12616000539437.
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http://dx.doi.org/10.1016/j.jtos.2019.11.009DOI Listing
January 2020

Diagnostic profile of tear osmolarity and inter-ocular variability for dry eye disease.

Clin Exp Ophthalmol 2020 03 2;48(2):255-257. Epub 2019 Dec 2.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ceo.13688DOI Listing
March 2020

Evaluating the diagnostic utility of evaporative dry eye disease markers.

Clin Exp Ophthalmol 2020 03 14;48(2):267-270. Epub 2019 Nov 14.

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ceo.13671DOI Listing
March 2020