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Research has shown that dry eye patients experience an improvement in corneal and conjunctival staining as well as symptom severity following instillation of autologous serum drops.1,2 These improvements have been noted as quickly as two to four weeks after initial use.1 And, because the biochemical properties of autologous serum drops are natural and similar to tears, they are extremely well tolerated.3
Blood and Tears
There is a significant biological overlap between blood serum and tears. More specifically, blood serum contains several essential tear film components, including epidermal growth factor, fibronectin, neurotrophic or nerve growth factor, and even vitamin A. Some or all of these tear film components are often depleted in patients with advanced cases of ocular surface disease.
Epidermal growth factor plays an important role in the regulation of cell growth and survival.4 Fibronectin is a high-molecular-weight glycoprotein that is integral to a healthy extracellular matrix. It binds key components, such as collagen, and is especially important for wound healing.5 Additionally, nerve growth factor is a protein that is critical for the growth, maintenance and survival of neurons; without nerve growth factor, apoptosis or cell death results.6
Obtaining Autologous Serum
Autologous tears are created by drawing a patient’s blood and then extracting the serum via centrifuge. The serum is mixed with artificial tears to create several autologous tear vials. Typically, a patient receives eight to 12 vials, which can be frozen and stored until required. One study indicated that freezing the drops effectively preserves the stability of essential autologous components, including epidermal growth factor, vitaminA and transforming growth factor beta.1 Also, no bacterial contamination has been documented in vials that were stored properly.7
In order to provide this service to your patients, typically you must first set up a blood draw with a lab. Then, the blood may be sent to either a compounding pharmacy or an eye bank (where corneal transplant tissues are processed and stored for most cities). Fortunately, many eye banks around the country are now offering this service.
The first application of autologous serum was documented in 1984.7 In this study, autologous drops were used in 15 patients who were diagnosed with keratoconjunctivitis sicca (KCS).7
In addition to the treatment of KCS, patients with persistent epithelial defects, Stevens-Johnson syndrome and/or ocular cicatricial pemphigoid have exhibited significant benefit from the use of autologous drops.2,8
Further, autologous drops may help in the management of patients who present with neurotrophic keratitis secondary to herpetic disease, keratoplasty, refractive surgery, diabetes and chemical burns.9
Finally, several studies have indicated that autologous drops can be used to treat recalcitrant recurrent corneal erosion (RCE), superior limbic keratoconjunctivitis and graft-versus-host disease as well as less common conditions, such as Mooren’s ulcers and aniridic keratopathy.3,10,11
In the original research for RCE, 11 patients had persistent episodes of erosion (a mean of 2.2 episodes per month).10 Just three of 11 patients treated with autologous drops experienced one breakdown during a three-month period.10 The other eight RCE patients had no episodes of recurrence.10
Of course, RCE is a long-term condition––so, three months of data may not be overwhelmingly telling. However, research in Greece on the long-term use of autologous serum drops in 33 RCE patients has been extremely promising.12 In this study, patients began using autologous serum drops when all previous treatment options for RCE failed. The patients dosed the autologous drops six times per day for three months, followed by q.i.d. for three additional months. Then, they discontinued the drops.
Following drop discontinuation, the researchers followed the patients for an average of 30 months. None of the patients experienced a recurrence during treatment. More remarkably, 85% of patients experienced complete healing of RCE with no recurrent episodes for 30 months following therapy.12 In fact, just five patients reported a single recurrence.12
Autologous Serum Alternatives
Some patients either cannot undergo proper blood draws or have insufficient volumes of blood to generate clinically viable autologous serum drops. In these cases, a compounding pharmacist may be able to create a tear drop with 5% albumin, which is one of the more important compounds found in blood plasma and tears.13
The use of “platelet-rich plasma” may be another alternative to autologous serum drops. Because blood that contains platelets provides a higher concentration of essential growth factors, it may yield an equally or more effective serum than albumin.14
Tears created with platelet-rich plasma have been tested successfully in patients with persistent epithelial defects, moderate to severe KCS, post-LASIK ocular surface syndrome and corneal perforation associated with amniotic membrane transplantation.15
In one study of 40 patients with persistent epithelial defects, 38 individuals showed significant improvement or complete resolution with the use of platelet-rich plasma drops. All patients reported reduced pain and improved vision.16
Optometrists often see patients who present with severe ocular surface disease. In some cases, conventional treatment options are ineffective. So, it is important to be aware of these blood-derived treatment options to provide optimal therapy for as many patients as possible.
The Effect of Autologous Platelet Lysate Eye Drops: An In Vivo Confocal Microscopy Study.
Fea AM1, Aragno V1, Testa V1, Machetta F1, Parisi S2, D'Antico S3, Spinetta R1, Fusaro E2, Grignolo FM1.
Purpose. To determine the effectiveness of autologous platelet lysate (APL) eye drops in patients with primary Sjögren syndrome (SS) dry eye, refractory to standard therapy, in comparison with patients treated with artificial tears. We focused on the effect of APL on cornea morphology with the in vivo confocal microscopy (IVCM). Methods. Patients were assigned to two groups: group A used autologous platelet lysate QID, and group B used preservative-free artificial tears QID, for 90 days. Ophthalmological assessments included ocular surface disease index (OSDI), best corrected visual acuity (BCVA), Schirmer test, fluorescein score, and breakup time (BUT). A subgroup of patients in group A underwent IVCM: corneal basal epithelium, subbasal nerves, Langerhans cells, anterior stroma activated keratocytes, and reflectivity were evaluated. Results. 60 eyes of 30 patients were enrolled; in group A (n = 20 patients) mean OSDI, fluorescein score, and BUT showed significant improvement compared with group B (n = 10 patients). The IVCM showed a significant increase in basal epithelium cells density and subbasal nerve plexus density and number and a decrease in Langerhans cells density (p < 0.05). Conclusion. APL was found effective in the treatment of SS dry eye. IVCM seems to be a useful tool to visualize cornea morphologic modifications.
THE way, to say goodbye, to dry eye
By Paul M. Karpecki, O.D., and Diana L. Shechtman, O.D.
The thought of drawing blood to create a solution that can be dropped into the eye seems odd, at best. But now, we are beginning to learn that autologous serum drops can be used to treat various ocular diseases both safely and effectively.
To evaluate the effectiveness of the autologous serum eye drops in the treatment of severe dry eye patients.
Prospective randomized case-control study.
Thirty-seven eyes of twenty severe dry eye patients without punctal occlusion were enrolled in this study. After 2 weeks of washout, they were randomly assigned to two groups. Group A patients used only preservative-free artificial tears, and group S patients used only autologous serum eyedrops. We evaluated the results of Schirmer test, fluorescein and rose bengal staining scores, tear film breakup time (BUT), and subjective symptom scores before and 2 weeks after treatment.
Mean BUT and fluorescein and rose bengal staining scores, as well as subjective symptom scores, showed significant improvement in the patients assigned to autologous serum eyedrops compared with subjects assigned to preservative-free artificial tears after 2 weeks of treatment.
Autologous serum eyedrops were found effective in the treatment of severe dry eye disease, as evidenced by improvement of tear stability and ocular surface vital staining scores.
Autologous serum eye drops for the treatment of dry eye diseases.
Kojima T1, Higuchi A, Goto E, Matsumoto Y, Dogru M, Tsubota K.
Conventional treatment of dry eye mainly consists of the use of preservative-free artificial eye drops and punctal occlusion. None of the commercially available artificial tear preparations include essential tear components such as epidermal growth factor, hepatocyte growth factor, fibronectin, neurotrophic growth factor, and vitamin A-all of which have been shown to play important roles in the maintenance of a healthy ocular surface epithelial milieu. We reported previously that autologous serum (AS) eye drops contain these essential factors and that AS eye drops are beneficial in the treatment of ocular surface diseases such as persistent epithelial defects, superior limbic keratoconjunctivitis, keratoconjunctivitis sicca, and neurotrophic keratopathy. However, there is some controversy regarding the efficacy of AS treatment. We demonstrated that this modality is more effective than artificial tears in a randomized control study. In in vivo and in vitro experiments, AS eye drops showed marked suppression of apoptosis in the conjunctival and corneal epithelium. Albumin, the major protein in serum, improved ocular surface damage in vivo and rescued apoptosis after serum deprivation in vitro. The biological background of AS eye drops and previous clinical studies of these medications for the treatment of dry eye are discussed.
The application of the autologous serum eye drops results in significant improvement of the conjunctival status inpatients with the dry eye syndrome.
[Article in Czech]
Jirsová K1, Hrdlicková E, Alfakih A, Juklová K, Filipec M, Faltus V, Veselá V.
1Laborator biologie a patologie oka, Ustav dĕdicných metabolických poruch VFN a 1. LF UK, Praha. firstname.lastname@example.org
To detect the changes on the conjunctiva surface before and after the application of the autologous serum (AS) eye drops in patients with dry eye syndrome, using both clinical and laboratory approaches, supplemented with subjective assessing the discomfort status.
MATERIALS AND METHODS:
The AS eye drops were applied during the period of 3 months in 8 patients with dry eye syndrome (Schirmer test < 5 mm and break-up time < 5 seconds), with the highest (maximum) frequency 8 times a day. The clinical (Schirmer test, break-up time, rose Bengal staining, examination of the tear meniscus, detritus and superficial punctate keratitis) and laboratory examinations (morphological assessment of the conjunctiva, detection of apoptotic cells) were performed at the start and at the end of the 3 months treatment period. Each day, patients reported their ocular status (dryness, discomfort, foreign body sensation, light sensitivity).
The AS eye drops application improved significantly the values of the Schirmer test,detritus and superficial punctate keratitis as well. The goblet cells density on the conjunctival surface increased and the number of apoptotic cells decreased. The intensity of unpleasant feelings reported by the patients decreased significantly in all of the assessed categories.
Because the application of AS eye drops caused the improvement of conjunctival status as well as the decrease of the severity of difficulties reported by the patients, the AS eye drops application should become common therapeutic practice in patients with dry eye syndrome.