A retrospective chart review was conducted at the cornea specialty clinic of Gachon University Gil Medical Center. The study protocol was approved by the institutional review board of Gachon University Gil Medical Center, and a waiver for collecting the informed consent along with authorization for using research information from the patients was also obtained from the review board (IRB number: GCIRB2019-388). Privacy data of all patients were not included in the analysis. The protocol complied with the tenets of the Declaration of Helsinki. The subjects who participated in this study enrolled between August 1, 2018, and August 12, 2020. Patients with DED who were aged ≥19 years were enrolled in this study in accordance with the diagnostic guidelines of the Korean Corneal Disease Study Group and TFOS DEWS II.1,2 The enrolled patients had been previously diagnosed with DED and referred from other eye clinics because there had been no improvement or acute exacerbation with topical CsA, DQA, and artificial tears. Only patients who had used CsA or DQA for at least 1 month or longer, but DED symptoms were not improved, or had had poor compliance due to the irritation feeling from those eyedrops, were included in this study. Patients with evidence of any active ocular infection, eyelid deformity, corneal opacity, or limbal stem cell deficiency were excluded from the study. The additional exclusion criteria were ocular surgery within 6 months of the study visit, ongoing pregnancy, and punctal plug placement within 3 months of testing. Subjects who used topical corticosteroids within 30 days of the study visit were also excluded. All the patients were administered topical corticosteroids and artificial tears, 4 times a day for 1 month [0.1% fluorometholone without preservative (Fumelon®; Hanlim Pharm. Co., Seoul, South Korea) + 0.15% sodium hyaluronate (New Hyaluni®, Taejoon Pharm Co., Seoul, South Korea) or 0.5% loteprednol etabonate (Lotepro®; Hanlim Pharm. Co., Seoul, South Korea) + 0.15% sodium hyaluronate (New Hyaluni®, Taejoon Pharm Co., Seoul, South Korea)]. The patients with MGD were recommended to perform warm compress and maintain eyelid hygiene.

At each visit, DED parameters of all patients were evaluated by an experienced ophthalmologist (DH Kim). The Symptom Assessment in Dry Eye (SANDE) questionnaire was conducted for evaluating the symptoms related to DED.21 The tear film break-up time (TBUT), tear secretion (Schirmer’s test without anesthesia), and ocular staining score (OSS) were also measured. The OSS was determined using the oxford scheme scale (0–5 points).22 MGD was classified into 5 stages (stages 0–4) according to the guideline prescribed by the International MGD workshop.22 The DED parameters were evaluated in the eye in which the patient felt more discomfort, and the right eye was evaluated if the symptoms were similar in both the eyes. Further surveys were conducted for simplifying the improvement in the subjective symptoms before and after topical corticosteroids treatment. Scores of 0, 1, and 2 indicated no improvement, partial improvement (better than before, but a little discomfort left), and complete improvement (no discomfort due to a greater improvement than before) after treatment, respectively. At each visit, the IOP was measured for all the patients with a pneumatic applanation tonometer (KOWA KT-800, Shizuoka, Japan). The patients visited the hospital after 1 month of treatment for a follow-up examination. The question whether warm compression and lid hygiene were performed after 1 month.

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