The Effect of a Pre-cataract Surgical Ocular Hygiene Regime on Microbial Load, Tear Osmolarity, Dry Eye, and Inflammatory Markers

Study Overview
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Brief Summary
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This study assesses the impact of two differing ocular hygiene regimens prior to cataract surgery. The first regimen includes an omega-3 supplement and the second without, and both include an at-home lid wipe and cleansing eye drops. These regimens will be assessed on microbial load, inflammation, tear osmolarity, and dry eye metrics. Patients will be randomized to either the omega-3 group + 3-part hygiene regimen, or the group with only the 3-part hygiene regimen. Data will be collected for inflammation through a test (InflammaDry) that measures an inflammatory marker, dry eye metrics via an imaging tool called Oculus 5M and the Canadian Dry Eye Assessment (CDEA) questionnaire, tear osmolarity through Tear Labs device, and area of growth for conjunctiva microbial load by swabbing the conjunctiva of the eye. Dry eye metrics (CDEA and Oculus 5M) will be collected during the patient's baseline appointment, 2-5 days prior to surgery, and post-operative month 1. Microbial load swabs will be collected at baseline, 2-5 days prior to surgery, and date of the surgery. An ocular assessment will also be completed at baseline, one week post-operation, and one month post-operation. All metrics will be compared to the fellow eye. The usage of omega-3 will be compared to the regimen without omega-3.

Detailed Description
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Prospective interventional study assessing the impact of two ocular hygiene regimens, with and without Omega-3, on microbial load, inflammation, tear osmolarity, and dry eye metrics and disease for patients soon to undergo cataract surgery. Study recruitment will occur at Uptown Eye between Sept-Nov 2023, with a target of 68 patients enrolled in the study. Patients will be consecutively randomized to group 1 (without omega 3 group) or group 2 (with omega 3 group). The intervention includes Zocular in clinic at baseline, Thealoz Duo eyedrops twice daily until surgery, and the cleansing wipes twice daily until surgery. The omega 3 group will take the supplement from baseline until one month post-operative. Data will be collected for inflammation through a InflammaDry Matrix metallopeptidase 9 (MMP-9) test, dry eye through Oculus 5M (measures non-invasive break-up time (NIBUT), lipid layer, bulbar redness, tear meniscus height) and Canadian Dry Eye Assessment (CDEA), TearLab for osmolarity, and conjunctival swabs for microbial load. Dry eye metrics (CDEA and Oculus 5M) will be collected during the patient's baseline Cataract Dry Eye Clinic (CDEC) appointment, 2-5 days prior to surgery, and post-operative month 1. Microbial load will be collected at baseline, 2-5 days prior to surgery, and date of the surgery. Tear osmolarity and inflammation markers will be collected at baseline, 2-5 days prior to surgery, and post-operative month. An ocular assessment will also be completed at baseline, one week post-operation, and post-operative month. All metrics will be compared to the fellow eye.

Official Title
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A Prospective Study on the Effect of Pre-cataract Surgical Ocular Hygiene Regime on Microbial Load, Tear Osmolarity, Dry Eye, and Inflammatory Markers Between Two Ocular Hygiene Regimen Groups

Conditions
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Dry Eye, Dry Eye Syndromes, Cataract

Intervention / Treatment
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* Dietary Supplement: Omega-3
* Drug: Trehalose
* Drug: Zocular Eyelid System Treatment
* Other: Blephadex cleansing eyelid wipes


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients 18 or older who underwent cataract surgical ocular hygiene treatment regimen prior to cataract surgery. Patients of all severity of dry eye will be included. Exclusion Criteria: Patients with any other ocular comorbidities (glaucoma, iritis, traumatic eye injury, known systemic autoimmune diseases, immune disorders, anti-inflammatory medications, blood disorders (eg. altered white counts), prior surgery, prior traumatic eye injury, previous dry eye interventions such as ocular plugs, radiofrequency, and IPL). Patients who have any complications arise during the cataract surgery. Patients with altered mental state and cannot provide informed consent.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients will be assigned to either the omega-3 group or no omega-3 group.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Omega-3<br>Participants in this arm will take oral omega-3 supplement for 4 weeks pre-operatively and 4 weeks post-operatively. They will also receive the Zocular intervention in clinic and the lid wipe and Thealoz eyedrops at home. | Dietary Supplement: Omega-3<br>* Omega-3 is a fatty acid and there is evidence that the consumption of re-esterified oral omega-3 supplements over the course of 6 to 8 weeks aid in reducing inflammation, dry eye, and optimizing tear osmolarity. The oral omega-3 supplement taken daily.<br>Drug: Trehalose<br>* Eyedrops consisting of trehalose and sodium hyaluronate that lubricate and hydrate the eye to relieve dry eye.<br>* Other names: Thealoz Duo Drops;Drug: Zocular Eyelid System Treatment<br>* A lid cleaning and debridement system that consists of okra-based gel to relieve dry eye or inflammation. The gel is applied to the eyelid margin and lashes with a cotton swab.<br>* Other names: ZEST;Other: Blephadex cleansing eyelid wipes<br>* Eyelid cleansing wipes with tea tree oil and coconut that help reduce infection.<br>|
| Active Comparator: No Omega-3<br>Participants in this arm will not take oral omega-3 supplement. They will only receive the Zocular intervention in clinic and the lid wipe and Thealoz eyedrops at home. | Drug: Trehalose<br>* Eyedrops consisting of trehalose and sodium hyaluronate that lubricate and hydrate the eye to relieve dry eye.<br>* Other names: Thealoz Duo Drops;Drug: Zocular Eyelid System Treatment<br>* A lid cleaning and debridement system that consists of okra-based gel to relieve dry eye or inflammation. The gel is applied to the eyelid margin and lashes with a cotton swab.<br>* Other names: ZEST;Other: Blephadex cleansing eyelid wipes<br>* Eyelid cleansing wipes with tea tree oil and coconut that help reduce infection.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| MMP-9 | Level of MMP-9, an inflammatory marker reported as positive (level of MMP-9 > 40ng/mL) or negative (level of MMP-9 < 40ng/mL). | Baseline, 2-5 days prior to surgery, post-operative month 1 | 
| Microbial load | Area of microbial growth from conjunctival swab reported as percentage of dish coverage, incubated for 48 hours | Baseline, 2-5 days prior to surgery, surgery day | 
| Tear osmolarity | Measure of salt concentration in tear reported as mOsm/L | Baseline, 2-5 days prior to surgery, surgery day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Non-invasive break-up time (NIBUT) | Non-invasive break-up time (NIBUT) is measured using the Oculus 5M and measured in seconds, with longer NIBUT representing better outcomes. | Baseline, 2-5 days prior to surgery, post-operative month 1 | 
| Lipid layer | Lipid layer is reported in nanometres with higher/thicker lipid layers representing a better outcome. | Baseline, 2-5 days prior to surgery, post-operative month 1 | 
| Bulbar redness | Bulbar redness is reported by a score from 0-4 with lower scores representing a better outcome. | Baseline, 2-5 days prior to surgery, post-operative month 1 | 
| Tear meniscus height | Tear meniscus height (TMH) is reported in millimetres, with increases in TMH representing a better outcome. | Baseline, 2-5 days prior to surgery, post-operative month 1 | 
| Canadian Dry Eye Assessment (CDEA) Questionnaire | 12 item questionnaire for reporting of dry eye symptoms on a scale of 0-4. Total scores for the CDEA questionnaire range from 0 to 48 and are interpreted as no dry eye symptoms or normal (<5), mild dry eye symptoms (5-20), moderate dry eye symptoms (21-30), or severe dry eye symptoms (31-48). | Baseline, 2-5 days prior to surgery, post-operative month 1 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Pre-operative, Ocular hygiene, Omega 3, Microbial load, Inflammation, Tear osmolarity