This review article provides information about recent advancements in treatment of dry eye management

1. Review Article : Latest
Advances in Dry Eye
Management
Moderator:
Mr. Sanjeeb Kumar Mishra
Presenters:
Gauri Chaudhary
Pooja Gurung

2. Presentation Layout
• Introduction to dry eye
• Classification of dry eye
• Diagnosis
• Treatment Modalities for dry eye
• Review Articles
• References

3. Introduction
According to Tear Film and Ocular Surface Society Dry Eye
Workshop II(TFOS DEWS II),
“Dry eye is a multifactorial disease of the ocular surface
characterized by loss of homoeostasis of the tear film, and
accompanied by ocular symptoms, in which tear film
instability and hyperosmolarity, ocular surface
inflammation and damage, and neurosensory abnormalities
play etiological roles”

4. Classification
• Holly and Lemp classified tear film abnormalities in 1977 into
following:
1. Aqueous deficiency, e.g. keratoconjunctivitis sicca, congenital
alacrima, paralytic hyposecretion
2. Soluble surfactant(mucin) deficiency, e.g. hypovitaminosis A,
Stevens-Johnson syndrome, drug induced disease
3. Lipid abnormality, e.g. chronic blepharitis
4. Impaired lid function, e.g. exposure keratitis, symblepharon,
pterygium
5. Epitheliopathy, e.g. anaesthetic cornea, epithelial irregularity

5. Etiological classification by DEWS report II
2017

6. Diagnosis
Symptoms
• Irritation
• FB sensation
• Feeling of dryness
• Itching
• Ocular discomfort
Signs
• Presence of stingy mucous and
particulate matter in tear film
• Conjunctiva gets lusterless, congested,
xerosed, keratinized
• PEE, filaments, mucous plaques on
cornea
• Signs of causative diseases as
blepharitis, MGDs, lagophthalmos

7. Tests for tear film adequacy
1. Schirmer test
2. Tear film break-up time
3. Vital staining with fluorescein, Rose Bengal, lissamine
green, alcian blue, scarlet red
4. Marginal tear film adequacy
5. Tear evaporimeter

8. Grading of dry eye by DEWS

9. Treatment modalities
Earlier treatment options :
1. Artificial tears
2. Warm compression
3. Hygiene with baby shampoo
4. Topical corticosteroids
5. Topical NSAIDS

10. Advancements in treatment
• Dry eye disease is the outcome of many factors resulting in
inflammation of the cornea and conjunctiva
• NSAIDs decrease the eye discomfort due to analgesic effect and
furthermore, reducing the inflammation
• Drugs mostly used are Rebamipide, Cyclosporine, Secretagogues
Medications

11. • CSA was discovered in the early 1970s as an antifungal agent; it is
a neutral, hydrophobic, cyclic metabolite of the fungi
Tolypocladium inflatum and Beauveria nevus
• Through its immunomodulatory effect, tCSA specifically blocks T-
cell activation and prevents synthesis of several proinflammatory
cytokines
• It decreases ocular inflammation and restores ocular surface
integrity, with increased tear production
Topical Cyclosporine

12. • Diquafosol sodium is an aqueous secretagogue that acts on P2Y2
receptors in the cornea and conjunctiva to promote the secretion
of water via an increase in intracellular calcium concentration
• Diquafosol stimulates the secretion of water from the cornea and
conjunctival epithelium and acts on goblet cells to promote the
secretion of secretory mucin
Aqueous and Mucin Secretagogues

13. • Rebamipide is a quinolinone derivative with mucin producing
activity
• It also has the effect of promoting recovery of tight junctions and
increasing the microvilli adhesion
• Rebamipide suppresses conjunctival TNF-α expression and
suppresses macrophage infiltration in a corneal epithelial wound
healing model
Rebamipide

14. • Approved by FDA in July, 2016, for the treatment of dry eye disease
• Mimics the intercellular adhesion molecule-1 (ICAM-1), blocking
interactions between ICAM-1 and lymphocyte functional associated
antigen-1 (LFA-1), which are instrumental in T-cell activation and
migration
• Gives improvement in both signs and symptoms of DED
Lifitegrast-5%

15. • Fox et al. first described the benefits of AS for the treatment of dry eyes
in patients with Sjogren’s syndrome
• Used for the purpose of supplying components to the ocular surface
that cannot be obtained by other topical eye drops
• Unpreserved, non-antigenic
• Biomechanical and biochemical properties similar to natural tears
• Prescribed for patients with
 Severe dry eyes d/t graft vs host disease and who did not respond to
other treatments
 Neurotrophic corneal ulcers
 Dry eye after laser sx
Autologous serum eye drops

16. Method of preparation for autologous serum eye drops
Blood collection from patient
Autologous serum
Sterilization by filtration
Dilution with 0.9% saline
Eye drops : 20% Diluted-autologous serum
Expiration 3 months at -20˚C, 2 weeks at 4˚C
Centrifugation for 10 mins at 1500 rpm

17. • Recent interest has grown in the use of other blood-derived products,
specifically eye-platelet rich plasma(E-PRP) and plasma rich in growth
factors(PGRF)
• Contain 3 to 5 times the platelet concentration compared with serum
drops
• Aim to maximize the concentration of growth factors, cell adhesion
molecules and alpha-granules released cytokines
Blood products

18. • An increase in the level of ROS outside mitochondria is
responsible for inflammation, a primary mechanism of dry eye
disease
• Oxidative injury from ROS occurs in the tears and conjunctiva of
Sjogren's syndrome patients, and high levels of ROS and oxidative
stress have been identified in the tear film of dry-eye patients and
in animal models of dry eye
• Antioxidants naturally present in tear film helps to control ROS
levels
Antioxidants

19. Devices

20. • More recently been used as an off-label treatment for
evaporative dry eye mediated by MGD, often in patients who also
suffer from rosacea
• Involves direct application of 500 nm light to the skin, coagulating
underlying blood vessels
• Proposed mechanisms of efficacy include reduced inflammatory
mediators and bacterial overgrowth by destruction of eyelid
telangiectasias as well as melting of viscous meibum, allowing
improved flow
Intense Pulsed Light

21. • Useful for in-office treatment of MGDs
• Lipiflow is a device that combines meibomian gland expression
with heat, in a technique referred to as vector thermal pulse
therapy
• During this procedure, the device applies heat over the palpebral
conjunctiva of the upper and lower eyelids, while providing
pulsatile external pressure
Vectored Thermal Pulsation(Lipiflow)

22. • A beveled, 2mm solid stainless steel probe is directly probed into
meibomian gland orifices
• As a result, there is growth of glands, partial restoration of faded
glands
Meibomian Gland probing

23. • Was designed to stimulate the mucosal nerves via small electrical
currents to increase natural tear production via the nasolacrimal
reflex pathway of the lacrimal function unit
Intranasal tear neurostimulation

24. Review Articles

25. Long-term outcome after topical
cyclosporin in severe dry eye
disease with a 10-year follow-up
Morgane Straub, Alain M Bron, Aurore Muselier-Mathieu, Catherine Creuzot-Garcher
Department of Ophthalmology, University Hospital, Lyon Sud, France; Department of
Ophthalmology, University Hospital, Dijon, France; Eye and Nutrition Research
Group, CSGA, UMR 1324 INRA, 6265 CNRS, Burgundy, Dijon, France
Straub M, et al. Br J Ophthalmol 2016;100:1547–1550. doi:10.1136/bjophthalmol-
2015-306930

26. Purpose
• To report the outcome of patients treated with an initial 6-month
induction phase with tCSA 0.05% (Restasis, Allergan,
Buckinghamshire, UK) followed by an ‘as-needed’ tCSA treatment
period during a 10-year follow-up

27. Methodology
• Patients suffering from moderate-to-severe KCS were enrolled in a
clinical trial conducted by Allergan (Study 192371-501) in May 2002 to
assess the efficacy and the safety of tCSA in patients with moderate-to-
severe dry eye
• All the patients were treated for at least 6 months
• VA, ocular pressure measurement and biomicroscopy was performed
by a single examiner
• The Schirmer I test, fluorescein and lissamine green staining scores and
tear film break-up time (TBUT) were recorded to assess clinical
symptoms before, during and after treatment and the subjective signs
were evaluated with the ocular surface disease index (OSDI)
questionnaire
• Prolongation and reintroduction of tCSA after the initial treatment and
combined treatments were also noted

28. Treatment procedure
Use topical CSA 0.05% twice daily for 6
months
If symptoms relieved, stop tCSA but
can continue artificial tear
If not, tCSA was prolonged and
prescribed twice daily as long as
necessary
Stop treatment if
symptoms relieved
In some cases, tCSA was
reintroduced during the
follow-up if needed
Period A
Period B
Period C

29. Results
• A total of 36 patients were included during period A, and 26 patients
were ultimately followed for 10 years
• Twenty-two patients had Sjogren's syndrome, one patient suffered
from sarcoidosis and another one from primitive biliary cirrhosis, two
patients presented xerostomia and xerophthalmia with KCS
• After a 10-year follow-up, the median duration of tCSA treatment was
23 (7–51) months (period A+B+C)
• All the patients still needed prolonged treatment with tCSA after the
first 6 months
• After this initial tCSA treatment period (A+B), only 6.5% needed
reintroduction of tCSA (period C)
• Only two patients were still taking tCSA after the 10-year follow-up

30. Contd…
• The overall number of topical lubricant eye-drops per day was
significantly lower during the tCSA treatment compared with baseline
• The number of corticosteroid eye-drops per day decreased
significantly from baseline to 6 months and 10 years
• Less ointment application was used at the end of the initial 6-month
tCSA treatment

31. Conclusion
• tCSA treatment decreased the objective clinical signs of KCS and
was associated in a long-term perspective with an improvement
of symptoms on everyday activities and a reduction of artificial
tear use

32. The efficacy of autologous serum eye
drops for severe dry eye syndrome: a
randomized double-blind crossover
study
Ali Riza Cenk Celebi & Cemalettin Ulusoy & G.
Ertugrul Mirza
Graefes Arch Clin Exp Ophthalmol
DOI 10.1007/s00417-014-2599-1

33. Purpose
• To evaluate the efficacy of a 1- month clinical trial of 20 % AS for
the treatment of severe DES based on Schirmer’s Test, tear break-
up time (TBUT), fluorescein staining, and OSDI scores, as
compared to conventional preservative-free artificial tears (PFAT)
treatment in patients with severe DES

34. Methodology
• The study included 20 patients (40 eyes) with severe DES that were
refractory to conventional treatment and had low TBUT (< 5 s), low
Schirmer’s Test score with using topical anesthesia (basic secretion <
5 mm m−1 ) , positive corneal and conjunctival fluorescein staining (≥
grade 1 according to the OXFORD Scale), and an OSDI score > 40
• Patients with active ocular infections and other inflammations were
excluded
• Each patient received a 16-vial treatment set with droppers
• All patients were instructed to keep the vials (containing either AS or
PFAT) in a refrigerator at 4 °C and were instructed to use four drops (1
every 6 h) in each eye

35. Contd…
• After the first 1-month treatment period, patients who had conventional
PFAT treatment were switched to AS treatment and the patients who
had AS treatment in the first 1-month treatment period were switched
to conventional PFAT treatment in the second 1-month treatment period
• OSDI, TBUT, Schirmer’s test, and OXFORD scales were administered by
the same ophthalmologist before and after both treatment periods

36. Results
• After first 1-month treatment period,
The mean difference in OSDI score, median difference in Schirmer’s
test result, TBUT value, and OXFORD between pretreatment and end
of 1st month was significant in both treatment groups
• At the end of second 1-month treatment period,
• Both AS and PFAT treatment improved OSDI scores, the median post
treatment TBUT value in the AS group improved significantly more
than that in the PFAT group, the median OXFORD cornea and
conjunctiva staining score decreased from III to II in both treatment
groups
• However, the values of median OXFORD cornea and conjunctiva
staining scores, median Schirmer’s test values did not vary
significantly between the 2 treatment groups

37. Conclusion
• This study confirmed that the observed improvements were due to AS
drops and that the effect was reversed when treatment was reversed
to PFAT therapy, indirectly indicating that the active components in AS
are required for the maintenance of a healthy ocular surface
• Treatment with AS is an effective method for replenishing a number of
growth factors that have been reduced in severe DES

38. Intense Pulsed Light Treatment for
Dry Eye Disease Due to Meibomian
Gland Dysfunction; A 3-Year
Retrospective Study
Rolando Toyos, MD, William McGill, PhD,2 and
Dustin Briscoe, OD
Photomedicine and Laser Surgery Volume 33,
Number 1, 2015 ª Mary Ann Liebert, Inc. Pp. 41–46
DOI: 10.1089/pho.2014.3819

39. Purpose
• To determine the clinical benefits of intense-pulsed-light therapy
for the treatment of dry-eye disease caused by meibomian gland
dysfunction (MGD)

40. Methodology
• A retrospective noncomparative interventional case series was
conducted with 91 patients presenting with severe dry eye syndrome
based, in most cases, on a combination of TBUT, abnormal meibum,
abnormal lid margins, and patient discomfort
• Treatment included intense-pulsed-light therapy and gland expression
at a single outpatient clinic over a 30-month study
• TBUT before and after IPL therapy was recorded

41. Result
• Out of 91 participants, pre/post changes in TBUT were available for
only 78 patients
• Primary outcomes included change in tear breakup time, self-reported
patient satisfaction, and adverse events
• Physician-judged improvement in dry eye tear breakup time was found
for 68 of 78 patients (87%) with seven treatment visits and four
maintenance visits on average, and 93% of patients reported post-
treatment satisfaction with degree of dry eye syndrome symptoms
• Redness or swelling, were found for 13% of patients while no serious
adverse events were found

42. Conclusion
The study results of intense-pulsed light therapy treatment for dry eye
syndrome caused by meibomian gland dysfunction are promising.

43. A randomized, double-blind,
placebo-controlled study of oral
antioxidant supplement therapy in
patients with dry eye syndrome
Jehn-Yu Huang Po-Ting Yeh Yu-Chih Hou
Department of Ophthalmology, National Taiwan University
Hospital, College of Medicine, National Taiwan University, Taipei,
Taiwan
Clinical Ophthalmology 2016:10 813–820

44. Purpose
• To evaluate the efficacy of oral antioxidant supplementation in
the treatment of patients with dry eye syndrome (DES)

45. Methodology
• Participants were divided into oral antioxidant group and placebo group
• Inclusion criteria:
• Age(20-75 yrs)
• Any 2 symptoms among burning sensation, dry eye sensation, itching,
pain, FB sensation
• basal Schirmer’s test values <5 mm at 5 minutes after topical 0.5%
proparacaine anesthesia
• tear film breakup time (TFBUT) < 10 seconds or
• positive corneal fluorescein staining
• Oral antioxidant group was administered a commercially available
antioxidant supplement containing anthocyanosides, astaxanthin,
vitamins A, C, and E, and crude extracted additives from several Chinese
herbal extracts in the form of caplet

46. • Placebo group was provided with placebo supplement containing starch
with natural food coloring
• Dry eye symptoms, visual acuity, Schirmer’s test, tear film breakup time,
cornea and conjunctiva fluorescein staining, serum anti-SSA/anti-SSB
antibodies, and the level of reactive oxygen species (ROS) in tears were
assessed
• Initial screening at outpatient clinic
• Washout period for 2 weeks
• Each patient received a caplet of the supplement or placebo twice daily
for 8 weeks
• Patients were followed up for an additional 8 weeks after discontinuing
supplementation
• Patients were followed up every 4 weeks for 16 weeks

47. Results
• Forty-three patients, 20 and 23 in treatment and placebo groups,
respectively, completed the study
• There were no significant differences in systolic blood pressure, dry
eye symptoms, serum anti-SSA and anti-SSB, visual acuity, intraocular
pressure,
• In the scores of the five subjective symptoms (burning sensation, dry
eye sensation, itching, pain, and foreign body sensation), there were
no significant differences between the two groups
• There were no significant differences in the clinical assessments of
discharge, foamy tears, conjunctival redness, and fluorescein staining
of the conjunctiva and cornea between the two groups; however,
corneal fluorescein staining improved after 2 months of
supplementation
• TFBUT was significantly improved after treatment in the treatment
group but not in the placebo group

48. Conclusion
Oral antioxidant supplementations may increase tear production
and improve tear film stability by reducing tear ROS. The vegetable-
based antioxidant supplement used in this study is safe and can be
utilized as an adjuvant therapy to conventional artificial tear
therapy for patients with DES.

49. Clinical results of Intraductal
Meibomian
gland probing combined with intense
pulsed light in treating patients with
refractory obstructive meibomian
gland
dysfunction: a randomized controlled
trial
Xiaodan Huang , Qiyu Qin , Linping Wang, Jiao Zheng, Lin Lin and Xiuming Jin
Huang et al. BMC Ophthalmology (2019) 19:211
https://doi.org/10.1186/s12886-019-1219-6

50. Purpose
• To optimize the therapeutic regimen for refractory obstructive
meibomian gland dysfunction (o-MGD) patients by combining
intraductal meibomian gland probing (MGP) and intense pulsed
light (IPL) to enhance their positive effects and reduce their
limitations

51. Methodology
• This randomized, assessor blind study includes 45 patients (90 eyes) with
refractory o-MGD who were divided into 3 groups via allocation
concealment: IPL (group I, received an IPL treatment course: 3 times at
3-week intervals), MGP (group II, received MGP one time), and combined
MGP-IPL (group III, MGP first followed by an IPL treatment course)
• Standard Patient Evaluation of Eye Dryness score (SPEED), tear break-up
time (TBUT), Corneal fluorescein staining (CFS), meibum grade, and lid
margin finding results were assessed at baseline, 3 weeks after final
treatment for groups I and III, 3 and 12 weeks after MGP for group II
• Six months after final treatment, the SPEED and willingness to receive
any treatment again were also collected for all groups

52. Results
• For all 3 groups, all previously mentioned indexes improved significantly
following treatment (P<0.01)
• MGP-IPL was better than IPL and MGP in terms of post-treatment
SPEED, TBUT, meibum grade, and lid telangiectasia (P<0.05/3)
• The MGP-IPL was better than IPL in terms of lid tenderness and better
than MGP in terms of orifice abnormality (P< 0.05/3)
• Six months later, the SPEED for the MGP-IPL was also significantly lower
than other groups (P<0.05/3)
• No patients in the MGP-IPL group expressed the need to be treated
again compared to 35.7% or 20% of patients in the IPL or MGP groups,
respectively

53. Conclusion
• IPL, MGP, and combined MGP-IPL are all effective methods for
refractory o-MGD patients; however, the combination MGP-IPL
method could maximize the therapeutic benefits, which is
especially helpful for patients who have severe meibomian gland
obstruction and obvious intraductal or eyelid margin
inflammation, who want to gain the greatest amelioration in all
clinical signs and subjective symptoms or still remain frustrated to
either MGP or IPL treatment

54. Effectiveness and relevant factors
of 2 % rebamipide ophthalmic
suspension treatment in dry eye
Kaori Ueda, Wataru Matsumiya , Keiko Otsuka, Yoshifumi Maeda,
Takayuki Nagai and Makoto Nakamura
Ueda et al. BMC Ophthalmology (2015) 15:58 DOI 10.1186/s12886-
015-0040-0

55. Purpose
• To evaluate the effect of 2 % rebamipide ophthalmic suspension
in patients with dry eye and analyze relevant factors for favorable
effects of rebamipide in clinical practice

56. Methodology
• This was a retrospective cohort study of 48 eyes from 24 patients with
dry eye treated with 2 % rebamipide ophthalmic suspension
• Dry eye-related symptom score, tear film break-up time (TBUT),
fluorescein ocular surface staining score (FOS) and the Schirmer test
were used to collect the data from patients at baseline, and at 2, 4, 8,
and 12 week visits
• To determine the relevant factors, multiple regression analyses were
then performed

57. Results
• Mean dry eye-related symptom score showed a significant improvement
from the baseline (14.5 points) at 2, 4, 8 and 12 weeks (9.80, 7.04, 7.04
and 7.83 points, corrected P value
• Median FOS showed a significant improvement from the baseline (3.0
points) at 2, 4, 8 and 12 weeks (2.0, 2.0, 1.0 and 1.0 points, corrected P
value
• TBUT and Schirmer test values were not significantly improved after the
treatment. For ocular symptoms, three parameters (foreign body
sensation, dry eye sensation and ocular discomfort) showed significant
improvements at all visits
• The multiple regression analyses showed that the fluorescein
conjunctiva staining score was significantly correlated with the changes
of dry eye-related symptom score at 12 weeks (P value = 0.017) and dry
eye-related symptom score was significantly correlated with
independent variables for the changes of FOS at 12 weeks (P value =
0.0097)

58. Conclusion
Two percent rebamipide ophthalmic suspension was an effective
therapy for dry eye patients. Moreover the fluorescein conjunctiva
staining score and dry eye-related symptom score might be good
relevant factors for favorable effects of rebamipide.

59. A single vectored thermal
pulsation treatment for
meibomian gland dysfunction
increases mean comfortable
contact lens wearing time by
approximately 4 hours per day
Caroline A Blackie, Christy A Coleman, Kelly K Nichols, Lyndon Jones, Peter Q Chen,
Ron Melton, David L Kading, Leslie E O’Dell, Sruthi Srinivasan
Clinical Ophthalmology 2018:12 169–183

60. Purpose
• To evaluate the effect of a single vectored thermal pulsation (VTP)
treatment in contact lens wearers with meibomian gland
dysfunction (MGD) and dry eye symptoms

61. Methodology
• The prospective, non significant risk, open-label, randomized, multi-
center clinical trial included 55 soft contact lens (SCL) wearers with
MGD and evaporative dry eye
• Subjects were randomized to the single VTP treatment group or an
untreated control
• The controls received a crossover VTP treatment at 3 months
(crossover treatment group)
• Primary effectiveness measures were meibomian gland secretion
(MGS) score and Standard Patient Evaluation of Eye Dryness (SPEED)
that were evaluated at baseline, at 1 and 3 months post-VTP treatment,
and at 1 month post-VTP treatment in the crossover treatment group
• Exploratory variables included fluorescein tear break-up time (TBUT),
lid wiper epitheliopathy (LWE), lid parallel conjunctival folds (LIPCOF),
ocular surface staining, frequency of over-the-counter (OTC) drop use,
and hours of comfortable contact lens wear

62. Results
• At 3 months, the treatment group showed significantly greater mean
change from baseline in MGS (12.4±9.1 vs 1.4±6.4, p,0.0001), SPEED
(−8.4±4.7 vs −0.7±4.4, p,0.0001) and significantly greater improvement in
exploratory variables (TBUT, LWE, and frequency of OTC drop use) relative
to the controls
• Mean comfortable contact lens wearing time increased by 4.0±3.9 hours
at 1 month
• This was sustained for 3 months with no change in the control group
• The crossover treatment group demonstrated similar results to the
treatment group at 1 month post-VTP

63. Conclusion
In SCL wearers with MGD, a single VTP treatment significantly
improved mean meibomian gland function and significantly reduced
dry eye signs and symptoms compared to an untreated control. The
treatment increased mean comfortable lens wearing time by 4 hours
(approximately doubling the pretreatment findings). This was
sustained for up to 3 months post-treatment on average

64. Evaluation of a Thermosensitive
Atelocollagen Punctal Plug
Treatment for Dry Eye Disease
Takashi Kojima, Yukihiro Matsumoto, Osama M.A.Ibrahim, Tais Hitomi
Wakamatsu, Murat Dogru, Kazuo Tsubota
http://dx.doi.org/10.1016/j.ajo.2013.10.019

65. Purpose
• To evaluate the efficacy of a thermosensitive atelocollagen
punctal plug in the treatment of dry eye disease

66. Methodology
• The thermosensitive atelocollagen punctal plug was warmed at 37˚C,
39˚C, 41˚C, and 43˚C to evaluate the appropriate temperature and
time for solidification
• Dry eye patients were divided into 2 groups according to the
preparation method of the atelocollagen punctal plug viz. conventional
implantation group and the preheating group
• In the conventional implantation group, atelocollagen gel was kept at
room temperature for 15 minutes before implantation (27 eyes of 14
patients)
• In the preheating group, atelocollagen was warmed at 41˚C for 8
minutes before implantation (23 eyes of 13 dry eye patients)
• Strip meniscometry, vital stainings, tear film break-up time (BUT), and
symptom scores were evaluated before and 1 month after plug
implantation

67. Results
• In vitro experiments revealed that heating at 41˚C for 8 minutes was
sufficient to solidify the gel
• The mean fluorescein score in the conventional implantation group
significantly improved after treatment (before, 3.5 ± 2.3 points; after,
2.5 ± 0.9 points, P<0.05)
• In the preheating group, the mean fluorescein score (before, 3.7 ± 1.7
points; after, 1.5 ± 1.2 points), strip meniscometry (before, 0.6 ± 0.7
mm; after, 1.1 ± 0.3 mm), BUT (before, 3.2 ± 0.7 seconds; after, 4.8 ±
1.0 seconds), and visual analog scale scores (before, 6.6 ± 1.5 points;
after, 4.1 ± 0.9 points) significantly improved after treatment (P < 0.05)

68. Conclusion
The thermosensitive atelocollagen punctal plug was effective for dry
eye treatment. The preheating method was found to be useful to
strengthen the efficacy of the thermosensitive atelocollagen punctal
plug.

69. Take Home Message

70. References
• Khurana, AK, Khurana, Indu, 2017, Anatomy and
Physiology of Eye, 3rd Edi, CBS Publishers &
Distributers Pvt. LTD.
• Khurana, AK, 2019, Comprehensive Ophthalmology,
7th Edi, Jaypee Brothers Medical Publishers
• Pubmed, Googlescholar, Hinari, Researchgate