Publications

2025 Clinical practice patterns in the management of dry eye disease: A TFOS international survey 2023-24

Journal Article

Authors

James S. Wolffsohn, David A. Semp, Debarun Dutta, Lyndon Jones, Jennifer P. Craig; the TFOS ambassadors

 

Abstract

Aims: To understand current clinical management of dry eye disease (DED), based on its perceived severity and subtype by practitioners across the world.

Methods: The content of the anonymous survey was chosen to reflect the DED management strategies reported by the Tear Film and Ocular Surface Society (TFOS) 2nd Dry Eye Workshop (DEWS II). Questions were designed to ascertain practitioner treatment choice, depending on the subtype and severity of DED. It was first created in English and then translated/back-translated into 14 languages for online completion.

Results: Completed surveys were received from 905 eye care practitioners (52% optometrists and 42% ophthalmologists) from across the globe. Many treatment strategies for DED were observed to be utilised by respondents, independent of severity and subtype, the most common being advice (82%), low (82%) and high (81%) viscosity unpreserved lubricants and lid wipes/scrubs (79%). Several treatments were prescribed across all severity levels (scaled from 1 mild to 10 severe), such as advice (median 4.5, range 4.8), artificial tears (median 5.1, range 4.6) and nutritional supplements (median 5.3, range 4.2). Others were prescribed more frequently with increasing disease severity, for instance, biologics (median 8.2, range 2.8) and surgical approaches (median 8.1, range 2.2). While a similar number of practitioners reported prescribing advice, artificial tears and anti-inflammatories regardless of DED subtype, the majority reported approaches for aqueous deficient DED were punctal occlusion, therapeutic contact lenses and secretagogues, while the use of oral essential fatty acids, topical lipid-containing products, lid hygiene and lid warming were the preferred management choices for evaporative DED.

Conclusions: There remains great variability in clinical approaches to DED management and until research-evidence definitively informs improved guidance, data from this survey can be used by clinicians to benchmark their practice.

  • BibTex Key
  • Authors David A Semp | Debarun Dutta | James S Wolffsohn | Jennifer P Craig | Lyndon Jones
  • Tags Dry eye disease | Management | Ocular surface | Severity | Subtype | Tear film | Therapy | Therapy Dry eye disease
  • DOI Number 10.1016/j.jtos.2024.12.008

    2025 In vitro anti-biofilm efficacy of therapeutic low dose 265 nm UVC

    Journal Article

    Authors

    Sanjay Marasini, Simon J Dean, Simon Swift, Jagir R Hussan, Jennifer P Craig

     

    Abstract

    Purpose: Preclinical studies have confirmed the safety and efficacy of narrowband low-intensity ultraviolet C light (UVC) in managing bacterial corneal infection. To further consolidate these findings, the present study aimed to explore in vitro anti-biofilm efficacy of low-intensity UVC light for its potential use in biofilm-related infections.

    Methods: Pseudomonas aeruginosa biofilm was grown in chamber well slides for 48 h and exposed to one of the following challenges: UVC (265 nm wavelength, intensity 1.93 mW/cm2) for 15 s, 30 s, 60 s or 120 s duration, 70% propanol (positive control), or no exposure (negative control). Bacterial LIVE/DEAD staining was conducted at 1 h, 4 h, 6 h and 8 h after challenge exposures to assess the temporal pattern of biofilm inactivation, and slides were imaged using confocal microscopy. Treatment efficacy was quantified by dead biofilm biomass (volume/area – μm3/μm2) for different treatment groups at each time point.

    Results: At each time point post-exposure, dead biofilm biomass was consistently higher in the alcohol- and UVC-challenged groups than in the unchallenged control (p < 0.05), suggesting a sustained biocidal impact after a given challenge. The quantity of dead biofilm biomass did not differ between UVC groups at any time point (p > 0.05). Observed by confocal microscopy, UVC-exposed biofilm demonstrated predominantly intermediate-stage biofilm (i.e., dying state) at 1 h, which progressed to dead biofilm by 4 h.

    Conclusion: Low doses of UVC demonstrated potent anti-biofilm activity, even in exposures as short as 15 s, the dose that has previously been deemed to be effective in managing corneal infection in vivo. These data support the potential for this UVC light-based technology to serve as an affordable, convenient, and effective means of treating ocular infections associated with bacterial biofilm.

    • BibTex Key
    • Authors Jagir R Hussan | Jennifer P Craig | Sanjay Marasini | Simon J Dean | Simon Swift
    • Tags Antimicrobial; Bacterial biofilm; Light-based anti-infective technology; Live/dead staining; UVC exposure.
    • DOI Number 10.1016/j.jphotobiol.2024.113091

      2025 Blink completeness and rate in dry eye disease: An investigator-masked, prospective registry-based, cross-sectional, prognostic study

      Journal Article

      Authors

      Michael T M Wang, Barry Power, Ally L Xue, Jennifer P Craig

       

      Abstract

      Purpose: To investigate the prognostic ability of blink rate and the proportion of incomplete blinking to predict dry eye disease diagnosis, as defined by the TFOS DEWS II criteria.

      Methods: A total of 453 community residents (282 females, 171 males; mean ± SD age, 37 ± 19 years) were recruited in an investigator-masked, prospective registry-based, cross-sectional, prognostic study. Dry eye symptomology, tear film quality, and ocular surface characteristics were assessed in a single clinical session, and blink parameters evaluated by an independent masked observer.

      Results: Overall, 214 (47 %) participants fulfilled the TFOS DEWS II criteria for dry eye disease. Multivariate regression analysis demonstrated that an increased proportion of incomplete blinking was associated with a higher odds of dry eye disease (odds ratio, 1.12 per 10 % increase; 95 % CI, 1.05-1.19; p < 0.001), with the Youden-optimal prognostic threshold proportion being ≥ 40 % incomplete blinking. Higher levels of incomplete blinking were also associated with poorer dry eye symptomology, tear film stability, corneal and lid margin staining, lipid layer thickness, meibography, and meibum quality (all p ≤ 0.03). No significant associations were detected between blink rate and ocular surface parameters (all p > 0.10).

      Conclusions: The degree of incomplete blinking is a significant predictor of dry eye disease, and the utility of incorporating blink assessment into diagnostic workup algorithms warrants further investigation. The association with meibomian gland dropout, expressed meibum quality, and lipid layer thickness would suggest that incomplete blinking may predispose towards the development of meibomian gland dysfunction.

      • BibTex Key
      • Authors Ally L Xue | Barry Power | Jennifer P Craig | Michael T M Wang
      • Tags Blinking | Diagnosis | Dry eye | Eyelid | Meibomian gland dysfunction | Ocular surface evaluation | Tear film
      • DOI Number 10.1016/j.clae.2025.102369

        2024 Diagnostic performance of qualitative and quantitative methods of meibomian gland dropout evaluation in dry eye disease: An investigator-masked, randomised crossover study

        Journal Article

        Authors

        Michael T M Wang, Barry Power, Ally L Xue, Ji Soo Kim, Jennifer P Craig

         

        Abstract

        Purpose: To evaluate the discriminative abilities and optimal cut-off values of qualitative meiboscale grading and percentage meibomian gland dropout measurements from each of two instruments (Keratograph 5M and LipiView II) in detecting dry eye disease, as defined by the TFOS DEWS II criteria.

        Methods: A total of 227 community residents (143 females, 84 males; mean ± SD age, 36 ± 15 years) were recruited in a prospective, investigator-masked, randomised, crossover study. Dry eye symptomology, tear film parameters, and ocular surface characteristics were evaluated in a single clinical session. Qualitative meiboscale grading and quantitative percentage gland dropout assessment using Image J software were evaluated by independent masked assessors, in a randomised order.

        Results: Overall, 92 (41 %) participants fulfilled the TFOS DEWS II criteria for dry eye disease. The diagnostic performances for percentage meibomian gland dropout measurements (C-statistic range, 0.629 to 0.647) were significantly greater than qualitative meiboscale grading (C-statistic range, 0.547 to 0.560) for both instruments. The Youden-optimal diagnostic cut-off percentage gland dropout was > 20 % and optimal threshold meiboscale grade was > 1 for both superior and inferior eyelid measurements from the two instruments. Inter-instrument weighted Cohen’s kappa coefficients for meiboscale grading were 0.734 and 0.682, respectively, and Bland-Altman biases (95 % limits of agreement) for percentage gland dropout were -1.8 % (-28.1 % to 24.4 %) and -1.5 % (-29.3 % to 26.2 %), respectively.

        Conclusions: Despite exhibiting comparable discriminative abilities, meibography parameters obtained from the Keratograph and LipiView were not directly interchangeable. Overall, percentage gland dropout measurements demonstrated superior diagnostic performance, which would support their use in clinical trials and epidemiology studies, where practicable.

        • BibTex Key
        • Authors Ally L Xue | Barry Power | Jennifer P Craig | Ji Soo Kim | Michael T M Wang
        • Tags Diagnosis | Dropout | Dry eye | Meibomian gland | Ocular surface | Tear film
        • DOI Number 10.1016/j.clae.2024.102324

          2024 Discriminative performance of ocular surface staining and lid wiper epitheliopathy in dry eye disease: An investigator-masked, prospective registry-based, diagnostic accuracy study

          Journal Article

          Authors

          Michael T M Wang, Barry Power, Ally L Xue, Jennifer P Craig

           

          Abstract

          Purpose: To evaluate the diagnostic performance of corneal and conjunctival staining, and lid wiper epitheliopathy (LWE) in detecting dry eye disease, as defined by the global consensus Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) criteria.

          Methods: A total of 2066 community residents (1285 females; mean ± SD age, 40 ± 19 years) were recruited in an investigator-masked, prospective registry-based, diagnostic accuracy study. Dry eye symptomology and ocular surface parameters were assessed in a single clinical session. The Sjögren’s International Collaborative Clinical Alliance (SICCA) corneal and conjunctival staining scoring and Korb lid wiper epitheliopathy (LWE) grading were evaluated by an independent masked assessor.

          Results: Overall, 807 (39 %) participants fulfilled the TFOS DEWS II criteria for dry eye disease, of which 178 (9 %) participants were classified as moderate-to-severe disease. The discriminative abilities of superior and inferior LWE (C-statistics, 0.724 and 0.712, respectively) were greater than corneal and conjunctival staining (C-statistics, 0.573 and 0.627, respectively). The Youden-optimal diagnostic cut-offs for the SICCA corneal and conjunctival staining scores were both ≥1, and the optimal thresholds for the Korb superior and inferior LWE grades were both ≥1. LWE was more commonly detected in both mild-to-moderate and moderate-to-severe dry eye disease, and demonstrated more consistent correlation with other ocular surface parameters across a broader range of disease severity.

          Conclusions: LWE demonstrates superior diagnostic performance relative to corneal and conjunctival staining. These findings would support the routine incorporation of LWE evaluation as part of the diagnostic workup of dry eye disease.

          • BibTex Key
          • Authors Ally L Xue | Barry Power | Jennifer P Craig | Michael T M Wang
          • Tags Conjunctiva | Cornea | Diagnosis | Dry eye | Lid Wiper | Ocular surface | Staining | Tear film
          • DOI Number 10.1016/j.jtos.2024.07.004

            2024 Diagnostic performance and optimal cut-off values for tear film lipid layer grading and thickness in dry eye disease: An investigator-masked, randomised crossover study

            Journal Article

            Authors

            Michael T M Wang, Barry Power, Ally L Xue, Jennifer P Craig

             

            No abstract available

            • BibTex Key
            • Authors Ally L Xue | Barry Power | Jennifer P Craig | Michael T M Wang
            • Tags Diagnosis | Dry eye | Interferometry | Lipid Layer | Meibomian gland | Ocular surface | Tear film
            • DOI Number 10.1016/j.jtos.2024.09.004

              2024 Meibomian gland tortuosity, truncation, and dilation in paediatric dry eye disease: A multi-centre, investigator-masked, cross-sectional study

              Journal Article

              Authors

              Michael T M Wang, James S Wolffsohn, Ji Soo Kim, Sophie Speakman, Edward Pritchard, Barry Power, Jennifer P Craig

               

              No abstract available

              • BibTex Key
              • Authors Barry Power | Edward Pritchard | James S Wolffsohn | Jennifer P Craig | Ji Soo Kim | Michael T M Wang | Sophie Speakman
              • Tags Dry eye | Eyelid | Meibomian gland | Ocular surface | Paediatric | Tear film
              • DOI Number 10.1016/j.jtos.2024.09.009

                2024 A novel framework for Indigenous eye health care in New Zealand: Ngā Mata o te Ariki

                Journal Article

                Authors

                Isaac Samuels, Mataroria Lyndon, Renata Watene, Jennifer P Craig

                 

                Abstract

                Clinical relevance: Development of an Indigenous eye health framework could offer the opportunity for eye health professionals to enhance engagement with Indigenous populations.

                Background: Indigenous populations globally experience disproportionately poorer eye health outcomes than non-Indigenous peoples. Incorporating Māori perspectives of eye care and pre-existing Indigenous models of health offers potential to enhance Māori experience and engagement with eye health services. This study seeks to develop and refine a practical framework for eye health care that incorporates nine established Indigenous health principles.

                Methods: Qualitative methodology, guided by Indigenous Māori research principles, was used to evaluate interviews with five leading senior Māori academics surrounding the ongoing development and refinement of a Kaupapa Māori (Māori worldview centric) framework for eye care in Aotearoa New Zealand, created following Māori health consumer consultation. Interviews were semi-structured and analysed using reflexive thematic analysis.

                Results: Seven key themes arose in relation to the development of a Kaupapa Māori framework for eye care in Aotearoa New Zealand: 1) vision is critical to Māori well-being, 2) cultural safety is important, 3) Māori health beliefs must be upheld, 4) achieving pae ora (healthy futures) is important, 5) key concepts and focus of the framework must be clear, 6) pūrākau (traditional Indigenous stories) are valuable resources in developing health frameworks and 7) embedding Matariki (fundamental Māori) principles is valuable.

                Conclusions: Using Kaupapa Māori principles allowed development and refinement of a framework that encourages clinicians to consider Indigenous health principles when engaging with Māori patients who seek eye care. Application of this framework may contribute to enhancing cultural safety and responsiveness of eye care for Māori.

                • BibTex Key
                • Authors Isaac Samuels | Jennifer P Craig | Mataroria Lyndon | Renata Watene
                • Tags Health Framework | Indigenous Eye Health | Kaupapa Māori | Māori Eye Health | Qualitative
                • DOI Number 10.1080/08164622.2024.2388139

                  2023 Electronic Cigarette Smoking and the Eyes

                  Journal Article

                  Authors

                  Michael T M Wang, Alexis Ceecee Britten-Jones, Jennifer P Craig

                   

                  No abstract available

                  • BibTex Key
                  • Authors Alexis Ceecee Britten-Jones | Jennifer P Craig | Michael T M Wang
                  • Tags
                  • DOI Number 10.1001/jamaophthalmol.2023.4020

                    2023 Ngā whakāro hauora Māori o te karu: Māori thoughts and considerations surrounding eye health

                    Journal Article

                    Authors

                    Isaac Samuels, Julie Pirere, Alex Muntz, Jennifer P Craig

                     

                    Abstract

                    Clinical relevance: Research highlighting Indigenous patient perspectives is essential in the pursuit of understanding and addressing longstanding health inequities.

                    Background: Evidence indicates that disparities in ocular health outcomes between Māori and non-Māori are pervasive in the New Zealand health system. Evidence shows the cause of these inequities is often multifactorial; due to factors such as colonisation, ongoing marginalisation, racism, socioeconomic status, poverty and culturally unsafe practice between health professionals and Māori patients.

                    Methods: This project used kaupapa Māori methodology to identify the perceptions of Māori surrounding ocular healthcare within a Māori context in Aotearoa New Zealand. Three focus groups with Māori community members and three individual interviews with Māori eyecare practitioners were conducted. Participants discussed sub-topics relating to Māori health, ocular health consultations, ocular examination and access to ocular health services in Aotearoa New Zealand. Reflexive thematic analysis was undertaken using NVivo qualitative research software.

                    Results: Five key themes were derived from the data: (1) the importance of effective clinician-patient communication; (2) historical experiences of patients inform their health attitudes; (3) barriers to access are systemic; (4) Māori health is important to Māori and (5) Te Ao Māori, Tikanga and Tapu are significant cultural concepts for Māori. Overall, Māori patients recognise the value of ocular healthcare and the importance of acknowledging Māori models of health within services.

                    Conclusion: The key issues Māori patients face within ocular health services resonate strongly with wider concepts intrinsically important to Māori. These are the right to cultural safety within clinical settings, the right to accurate and pertinent communication of information between clinician and patient and the respect of cultural beliefs and acknowledgement of power imbalances within the wider healthcare system. Participant discussions and suggestions raise possible pathways to begin addressing ocular ethnic disparities in healthcare delivery.

                    • BibTex Key
                    • Authors Alex Muntz | Isaac Samuels | Jennifer P Craig | Julie Pirere
                    • Tags Indigenous Eye Health | Kaupapa Māori | Māori Health | New Zealand | Qualitative Research
                    • DOI Number 10.1080/08164622.2022.2136513

                      2023 Omega-3 polyunsaturated fatty acids and corneal nerve health: Current evidence and future directions

                      Journal Article

                      Authors

                      Alexis Ceecee Britten-Jones, Jennifer P Craig, Laura E Downie

                       

                      Abstract

                      Corneal nerves play a key role in maintaining ocular surface integrity. Corneal nerve damage, from local or systemic conditions, can lead to ocular discomfort, pain, and, if poorly managed, neurotrophic keratopathy. Omega-3 polyunsaturated fatty acids (PUFAs) are essential dietary components that play a key role in neural development, maintenance, and function. Their potential application in modulating ocular and systemic inflammation has been widely reported. Omega-3 PUFAs and their metabolites also have neuroprotective properties and can confer benefit in neurodegenerative disease. Several preclinical studies have shown that topical administration of omega-3 PUFA-derived lipid mediators promote corneal nerve recovery following corneal surgery. Dietary omega-3 PUFA supplementation can also reduce corneal epithelial nerve loss and promote corneal nerve regeneration in diabetes. Omega-3 PUFAs and their lipid mediators thus show promise as therapeutic approaches to modulate corneal nerve health in ocular and systemic disease. This review discusses the role of dietary omega-3 PUFAs in maintaining ocular surface health and summarizes the possible applications of omega-3 PUFAs in the management of ocular and systemic conditions that cause corneal nerve damage. In examining the current evidence, this review also highlights relatively underexplored applications of omega-3 PUFAs in conferring neuroprotection and addresses their therapeutic potential in mediating corneal nerve regeneration.

                      • BibTex Key
                      • Authors Alexis Ceecee Britten-Jones | Jennifer P Craig | Laura E Downie
                      • Tags Fatty Acids | Omega-3
                      • DOI Number 10.1016/j.jtos.2022.10.006

                        2022 Preparation and Characterisation of a Cyclodextrin-Complexed Mānuka Honey Microemulsion for Eyelid Application

                        Journal Article

                        Authors

                        Ilva D Rupenthal, Priyanka Agarwal, Benedict Uy, Jaeun Kim, Angela A Cunningham, Ali Seyfoddin, Simon Swift, Jennifer P Craig

                         

                        Abstract

                        Honey has been widely purported as a natural remedy due to its antimicrobial and anti-inflammatory effects. In recent years, several studies have suggested that the considerably high methylglyoxal (MGO) concentration in Mānuka honey (MH) makes it particularly effective to manage bacterial overload, such as that observed in blepharitis. However, the poor solubility, high viscosity, and osmolarity of aqueous honey solutions, especially at the high MGO concentrations studied in the literature, render the formulation of an acceptable dosage form for topical application to the eyelids challenging. Here, the antibacterial properties of raw MH and alpha-cyclodextrin (α-CD)-complexed MH were evaluated at relatively low MGO concentrations, and a liquid crystalline-forming microemulsion containing α-CD-complexed MH was formulated. After determining pH and osmolarity, ocular tolerability was assessed using human primary corneal epithelial cells and chorioallantoic membranes, while the antibacterial efficacy was further evaluated in vitro. The α-CD-MH complex had significantly greater antibacterial activity against Staphylococcus aureus than either constituent alone, which was evident even when formulated as a microemulsion. Moreover, the final formulation had a physiologically acceptable pH and osmolarity for eyelid application and was well-tolerated when diluted 1:10 with artificial tear fluid, as expected to be the case after accidental exposure to the ocular surface in the clinical setting. Thus, a safe and efficient MH dosage form was developed for topical application to the eyelids, which can potentially be used to support optimal eyelid health in the management of blepharitis.

                        • BibTex Key
                        • Authors Ali Seyfoddin | Angela A Cunningham | Benedict Uy | Ilva D Rupenthal | Jaeun Kim | Jennifer P Craig | Priyanka Agarwal | Simon Swift
                        • Tags Antimicrobial | Blepharitis | Cyclodextrin | Mānuka Honey | Microemulsion | Tolerability
                        • DOI Number 10.3390/pharmaceutics14071493