Severe symptoms of short tear break-up time dry eye are associated with accommodative microfluctuations

Figures & data

Table 1 Profile of symptoms, baseline clinical signs, and treatments

No	Age (years)	Sex	Symptoms	Baseline refractive value (D)	Baseline range of accommodation (D)	Baseline DE signs			Previously administered treatments	Additional treatments	Follow-up period (days)
						Schirmer (mm)	BUT (second)	ST (score)
1	56	Female	Eye dryness	0.19	−1.66	6	3	0	Sodium hyaluronate solution	Diquafosol tetrasodium instillation, DE moisture glasses	63
2	26	Female	Eye dryness, ocular fatigue	2.56	−2.54	15	0	1	Sodium hyaluronate and diquafosol tetrasodium solution	Lacrimal punctal plugs at superior and inferior puncta, DE moisture glasses	63
3	40	Female	Smarting, eye pain	3.33	−1.75	6	0	0	Sodium hyaluronate solution	Diquafosol tetrasodium solution	42
4	42	Female	Eye dryness	2.24	−1.48	6	0	0	Sodium hyaluronate and rebamipide solution	Thermosensitive atelocollagen punctal plug (Keeptear^®)	56
5	60	Female	Eye dryness, ocular fatigue	0.59	−1.21	9	3	0	Sodium hyaluronate, rebamipide, and flavin adenine dinucleotide sodium solution	Diquafosol tetrasodium solution, lacrimal punctal plugs	94
6	36	Female	Eye dryness, eye pain	0.86	−4.68	10	4	0	Sodium hyaluronate, rebamipide, and flavin adenine dinucleotide sodium solution	Diquafosol tetrasodium solution, lacrimal punctal plugs	70
7	34	Female	Eye dryness, eye pain	2.84	−1.18	6	2	0	Sodium hyaluronate, diquafosol tetrasodium, and rebamipide solution	Lid hygiene, lacrimal punctal plugs	49
8	72	Male	Blurred vision, ocular fatigue	0.77	−0.59	6	1	0	–	DE moisture glasses	63
9	77	Male	Foreign body sensation, blurred vision	0.94	0.35	7	3	0	Diquafosol tetrasodium solution	Sodium hyaluronate, lacrimal punctal plugs	49
10	63	Male	Eye dryness, ocular fatigue	0.45	−3.02	8	0	0	–	Hyaluronic acid and diquafosol tetrasodium solution	35
11	23	Male	Blurred vision, dazzling sensation	2.02	−0.29	11	2	2	–	Hyaluronic acid and diquafosol tetrasodium solution	42
12	66	Female	Eye dryness, foreign body sensation	0.69	−6.59	8	5	0	Sodium hyaluronate solution	Diquafosol tetrasodium instillation	56

Abbreviations: BUT, break up time; DE, dry eye; ST, staining.

Figure 1 Functional VA and accommodative parameters before and after additional treatments.

Notes: (A) Starting VA and functional VA: Starting VA was defined as the standard best-corrected VA, as measured by the Functional VA Measurement System; functional VA was defined as the average of all VA values measured over time. LogMAR of functional VA significantly improved (P<0.05), while the mean logMAR of conventional VA did not show any statistically significant difference before and after treatment (P>0.05). (B) Visual maintenance ratio: Visual maintenance ratio was defined as the functional VA divided by the starting VA. (C) Blink frequency: The blink frequency was automatically recorded by a functional VA measurement device. (D) Accommodative parameters. The mean values of the power spectrum for HFC1 and total HFC significantly decreased (P<0.05), while the mean value of the power spectrum for HFC2 did not show any statistically significant difference before and after treatment (P>0.05).
Abbreviations: HFC, high-frequency component; logMAR, logarithm of the minimum angle of resolution; VA, visual acuity; VMR, visual maintenance ratio.

Figure 2 Fk-map and visual changes over time in a young patient.

Notes: (A) Tear film on the ocular surface before additional treatments. (B) Functional VA before the additional treatments. (C) Fk-map before the additional treatments. (D) Tear film on the ocular surface after the additional treatments. (E) Functional VA after the additional treatments. (F) Fk-map after the additional treatments. A 26-year-old woman (Case No 2) suffered from DE which was unresponsive to treatment. The BUT value was 0 s (A). Visual large fluctuation (B) and high appearance of HFC1 (C) were observed. Two months after the additional treatment consisting of insertion of lacrimal plugs to the superior and inferior lacrimal puncta and wearing DE moisture glasses, the DE symptoms completely resolved. The BUT value improved to 9 s (D). Likewise, functional VA (E) and accommodative parameters (F) improved.
Abbreviations: BUT, break-up time; DE, dry eye; Fk-map, frequency of kinetic reaction-map; HFC, high-frequency component; VA, visual acuity.

Figure 3 Fk-map and visual changes over time in an elderly patient.

Notes: (A) Tear film on the ocular surface before additional treatments. (B) Functional VA before the additional treatments. (C) Fk-map before the additional treatments. (D) Tear film on the ocular surface after the additional treatments. (E) Functional VA after the additional treatments. (F) Fk-map after the additional treatments. A 63-year-old man (Case No 10) suffered from severe DE sensation and ocular fatigue over the past years. A previously performed lacrimal plug insertion in the lacrimal puncta was maladaptive, and was removed because of foreign body sensation. The Fk-map showed a pattern of presbyopia (B). After topical administration of 0.1% sodium hyaluronate and 3% diquafosol tetrasodium, DE symptoms slightly improved. The BUT value improved from 0 to 8 s, and no fluorescein staining was observed (A, D). Functional VA (E) and accommodative parameters improved 1 month after treatment (F).
Abbreviations: DE, dry eye; BUT, break-up time; Fk-map, frequency of kinetic reaction-map; HFC, high-frequency component; VA, visual acuity.

Figure 4 The mechanism of occurrence of dry eye symptoms. Image defocus due to tear instability represents visual impairment.

Note: Blurring may possibly cause ciliary muscle spasms, which eventually induce AMF and cause DE symptoms including ocular fatigue.
Abbreviations: AMF, accommodative microfluctuation; DE, dry eye.