972026

research-article2020
EJO0010.1177/1120672120972026European Journal of OphthalmologySerrano-Morales et al.

EJO European
Journal of
Ophthalmology
Original research article
European Journal of Ophthalmology

Efficacy of 0.1% crosslinked hyaluronic

1­–6
© The Author(s) 2020
Article reuse guidelines:
acid, coenzyme Q10 and vitamin E in sagepub.com/journals-permissions
https://doi.org/10.1177/1120672120972026
DOI: 10.1177/1120672120972026

the management of dry eye disease journals.sagepub.com/home/ejo

in menopause patients receiving

antidepressants

José-Manuel Serrano-Morales, Concepción De-Hita-Cantalejo,

María Carmen Sánchez-González, María-José Bautista-Llamas
and José-María Sánchez-González 

Abstract
Purpose: The purpose of this study is to test non-inferiority of a lower dose of crosslinked hyaluronic acid (CLHA) to
a higher dose of carmellose eye drop in menopause patients receiving antidepressant treatments.
Methods: This prospective, double-blind, single-center study enrolled sixty female patients. Mean age was
63.25 ± 9.13 years. We examined patients with Schirmer I, breakup time (TBUT) and the ocular surface disease index
(OSDI) at the first visit. Tear A eyedrops were formulated with crosslinked hyaluronic acid, coenzyme Q10 and vitamin
E. Control tear B was formulated with carmellose sodium. Posology was two and five times, respectively.
Results: After 2 months of treatment, the tear A obtained 14.12 ± 7.47 score points for OSDI (t = 11.74, p < 0.01),
and tear B obtained 19.46 ± 10.03 score points (t = 7.59, p < 0.01). The tear A obtained 13.77 ± 7.78 score points for
Schirmer test (t = 0.88, p > 0.05), and tear B obtained 14.20 ± 8.62 score points (t = 2.92, p < 0.01). The tear A obtained
8.30 ± 2.08 s for TBUT (t = 15.50, p < 0.01), and tear B obtained 7.23 ± 2.40 s (t = 8.79, p < 0.01).
Conclusion: Lower total daily dose of crosslinked hyaluronic acid eyedrops obtained similar efficacy results in terms
of tear stability and subjective dry eye sensation than higher carmellose total daily dose. A lower total daily dose of
crosslinked eyedrops was sufficient to achieve better dry eye disease management compared to carmellose.

Keywords
Crosslinked hyaluronic acid, coenzyme Q10, dry eye, eyedrops, antidepressant

Date received: 24 January 2020; accepted: 18 October 2020

Introduction characteristics of the tear film and preserves its integrity

and corneal transparency and the quality of the images
Dry eye is a multifactorial disease of tears and the ocular projected to the retina.3 When direct or disease-derived
surface that manifests as discomfort, vision disturbances
and instability of the tear film, which may damage the ocu-
lar surface.1 It generally affects bilaterally and chronically.
Department of Physics of Condensed Matter, Optics Area, University
Dry eye is generally accompanied by an increase in the of Seville, Seville, Andalucia, Spain
osmolarity of the tear film and inflammation of the ocular
Corresponding author:
surface.2 Dry eye is a variation of the lacrimal functional
José-María Sánchez-González, Department of Physics of Condensed
unit (LFU), which includes the tear and meibomian glands, Matter, Optics Area, University of Seville, Reina Mercedes Street,
the ocular surface (cornea and conjunctiva), the eyelids Seville, Andalucia 41012, Spain.
and sensory and motor nerves. The LFU determines the Email: [email protected]
2 European Journal of Ophthalmology 00(0)

damage occurs to LFU components, there is a risk of tear Methods

film destabilization that may manifest itself as dry eye.
The epithelium will therefore be dry, the mucin will not be Design
fixed, and the aqueous layer will not properly form on the This prospective, double-blind, single-center and longitu-
affected corneal surface.4 Damage to the ocular surface dinal study was performed between October 2018 and
triggers the activation of sensory nerves, which results in June 2019 at the facilities of the School of Pharmacy
the perception of symptoms, such as eye burning, foreign (Optics and Optometry department) of the University of
body sensation, itching, blurred vision, decreased vision, Seville. The study was performed in accordance with the
dryness, photophobia, eye fatigue, and red eye.5 Ethical Committee Board of Andalusia and conducted
Menopause is one of the most common causes of dry according to the Declaration of Helsinki.
eye.6 Decreased sex hormones (estrogen and progester-
one) cause alterations in the surface of the epithelium and
alterations in secretions of the lacrimal gland and meibo- Subjects
mian glands. Treatment with systemic or local androgen Sixty female patients were enrolled in this study. All sub-
showed promising results in improving symptoms.7 The jects read, understood and signed an inform consent. The
administration of some oral drugs may aggravate or cause following inclusion criteria were used: (1) women in men-
dry eye disease (DED). Tear hyposecretion disappears opause or the postmenopausal period; (2) active antide-
shortly after the cessation of medication. The main drugs pressant or anxiolytics treatment; and (3) ocular surface
that cause problems of dry eyes are anxiolytics, antide- disease index (OSDI) punctuation above 13 points. The
pressants, antihistamines, antihypertensives, diuretics, following exclusion criteria were used: (1) soft or rigid
bronchodilators, and strong analgesics.8 gas-permeable contact lens use; (2) eyedrop use 1 month
Artificial tears are a topically administered pharma- before the first instillation; (3) any previous eye surgery;
ceutical product formulated to relieve the symptomatol- (4) inability to understand informed consent; and (5) ina-
ogy of dry eye and supplement natural tears. These bility to comply with the proposed follow-up. Sixty-three
products should contain a high water content and pos- of the total 78 patients met the inclusion and exclusion cri-
sess physicochemical characteristics that are similar to teria. Three of the patients were excluded for noncompli-
natural tears, including osmolarity, pH, viscosity, and ance with the installation guidelines.
surface tension.9 Among the many artificial tear compo-
nents, mucopolysaccharides stand out. These compo-
nents are polysaccharides with viscoelastic properties, Materials
and the viscosity varies depending on the stress to which An eye slit lamp test was utilized to study the tear, and
they are subjected. At rest, the viscosity is high, but the fluorescein stripes (Bio Glo ContaCare Ophthalmics &
viscosity decreases. This property of mucopolysaccha- Diagnostics, Gujarat, India) soaked with saline solution
rides improves blurred vision compared to cellulose were used for the breakup time test (TBUT). Tears were
polymers. Hyaluronic acid, at concentrations of 0.1%, analyzed employing the cobalt blue filter of the slit lamp.
0.15%, and 0.18%, is the main mucopolysaccharide Schirmer strip (Tear Flo, HUB Pharmaceutical, Plymouth,
used. Increasing the concentration decreases the surface MI) was used to quantify tear volume. The Schirmer strip
tension and increases contact with the ocular surface.10 was located among the outer and middle third of the lower
Hyaluronic acid was recently crosslinked and efficacy eyelid for 5 min, and the soaked length was measured in
was improved11 versus non-crosslinked hyaluronic acid millimeters. The site, moment in time, and moisture condi-
(CHA). This kind of artificial tears has been mixed with tions were the same for all patients examined. The patients
coenzyme Q10 and vitamin E. Due to the reticulated struc- also achieved the Ocular Surface Disease Index (OSDI)
ture of hyaluronic acid, a lubricating liquid matrix is questionnaire throughout the first appointment and a ques-
formed on the ocular surface. This matrix includes mole- tionnaire about their personal information, contact lenses
cules of coenzyme Q10 and vitamin E, which enhance type, and wearing time.
their antioxidant effect. Coenzyme Q10 also provides a Tear A eyedrops (VisuXL®, VISUfarma B.V®,
source of energy and protection against oxidative stress to Amsterdam, The Netherlands) were formulated with
cells on the ocular surface, which facilitates repair of the 100 mg crosslinked hyaluronic acid (CLHA) sodium salt,
tissue damage caused by dry eyes.12 100 mg of coenzyme Q10 (CQ10) and 500 mg of vitamin E
The purpose of this study is to test non-inferiority of a TPGS (D-α-tocopherol polyethylene glycol succinate).
lower total daily dose of crosslinked hyaluronic acid The vitamin is a solubilizing agent for the CQ10 lipids. All
(CLHA) to a higher total daily dose of carmellose eye drop of the components were dissolved in an isotonic buffered
in menopause patients receiving antidepressant treatments. solution of 100 ml. The package was a 10-ml multidose
Efficacy based on posology is also compared. bottle. Control tear B (Xailing Fresh®, VISUfarma B.V®,
Serrano-Morales et al. 3

Amsterdam, The Netherlands) was formulated with

500 mg carmellose sodium in an isotonic buffered solution
of 100 ml. The package contained 30 single 0.4-ml doses.
The doses were packaged for daily use, and the eyedrops
could not be used 12 h after the dose dispenser was opened.
These formulations were preservative-free lubricants.

Procedure
The study design comprised three phases. Potential
patients were identified, and their inclusion or exclusion
was evaluated in the first phase. Patients were recruited
during prescription dispensing in the pharmacy office, and
participation in the study was offered to people receiving Figure 1.  Subjective dry eye symptoms using the ocular
surface disease index (OSDI). Comparative boxplots of
tricyclic antidepressants (amitriptyline) or benzodiaz- crosslinked hyaluronic acid with coenzyme Q10 and vitamin E
epines anxiolytics (diazepam or lorazepam). These patients eyedrop versus carmellose eyedrops.
underwent an OSDI (Ocular Surface Disease Index) test to
evaluate their fitness for inclusion in the study. Tear meas-
urements were performed prior to treatment in the second qualitative variables and the means and SD. Student’s
phase. All patients in the study avoided the use of artificial t-test was performed between the two groups, and the
tears or eye drops for 1 month. After this period, patients effect size was calculated with D of Cohen13 formula. All
were given instructions on the proper instillation technique statistical tests were performed with a 95% confidence
for artificial tears. We examined the selected patients with level (p < 0.05).
Schirmer I, tear break up time (TBUT) and the ocular sur-
face disease index (OSDI) at the first visit. The amount of Results
tears was measured by a Schirmer test, and the quality was
measured using a TBUT test with fluorescein and blue The mean age of the patients was 63.25 ± 9.13 (45–85)
light. Corneal staining was explored through the TBUT years. Artificial tear A group had an OSDI of 30.45 ± 
and was negative in all cases. These tests were performed 10.02 (13.75–47.92) score points prior to treatment. The
in a blinded manner. Patients were given sufficient artifi- Schirmer test was 12.70 ± 10.91 (1–35) mm, and the
cial tears for 2 months and the patient instruction sheet, TBUT test was 4.03 ± 1.24 (2–8) s. Artificial tear B
which indicated the dose, during this same visit. Patients group reported an OSDI test of 31.20 ± 8.17 (17.50–
who received carmellose instilled the drops five times 46.29) score points, which was no significantly different
daily, and patients who received CLHA tears instilled the from the values for group A (p = 0.75). The Schirmer test
drops twice daily. The third phase consisted of tear meas- was 11.73 ± 9.71 (1–35) millimeters (mm) and was not
urements at the end of the treatment. After 2 months, the significantly different from the results of group A
patients were checked again, and the OSDI test, Schirmer (p = 0.71), and the breakup time (TBUT) test was
and TBUT were performed. The results of this second con- 4.27 ± 1.46 (1–7) seconds (s) and was not significantly
sultation were recorded in another document than the pre- different from the results of group A (p = 0.50).
vious results to avoid subjective bias of the researcher.
These second measurements were performed without
knowledge of the type of tear received. Patients were asso-
Ocular Surface Disease Index (OSDI)
ciated with a number to preserve anonymity. Two different In relation to OSDI, the artificial tear A group obtained
records were maintained: one record contained the results 14.12 ±  7.47 (2.50–29.65) score points (t = 11.74,
of the tests, and the other included the type of tears that p < 0.01). This supposes a large effect size of 1.84. The
were randomly assigned. The data of both records were OSDI decreased to 16.33 ± 7.61 (13.49–19.18, 95% confi-
crossed after study completion to obtain the results. dence interval) score points. The artificial tear B group
obtained 19.46 ± 10.03 (2.80–38.50) score points (t = 7.59,
p < 0.01). This supposes a large effect size of 1.28. The
Statistical analysis
OSDI decreased to 11.74 ± 8.46 (8.57–14.90, 95% confi-
The data were analyzed using the SPSS 25 package for dence interval) score points. Differences are reported in
Windows (SPSS Science, Chicago, IL). The normality of Figure 1. Post-treatment comparisons between the artifi-
the variables was verified using the Shapiro-Wilk test. A cial tears revealed that group A obtained better results with
descriptive data analysis technique was developed and a difference of 5.34 ± 2.28 (0.76–9.91, 95% confidence
showed the count and proportion in each category of the interval) score points (t = 2.33, p < 0.05).
4 European Journal of Ophthalmology 00(0)

Figure 2.  Tear volume using the Schirmer I test. Comparative

boxplots of crosslinked hyaluronic acid with coenzyme Q10 Figure 3.  Tear stability with breakup time (TBUT).
and vitamin E eyedrop versus carmellose eyedrops. Comparative boxplots of crosslinked hyaluronic acid with
coenzyme Q10 and vitamin E eyedrop versus carmellose
eyedrops.
Schirmer test
In relation to the measured tear volume, the artificial tear A clinical signs and symptoms compared to higher total daily
group obtained 13.77 ± 7.78 (2–35) score points (t = 0.88, dose carmellose eyedrops.
p > 0.05). This supposes a small effect size of 0.11. The use of hyaluronic acid in patients with moderate to
Schirmer increased only 1.06 ± 6.62 (1.40–3.5, 95% con- severe dry eye syndrome had been widely studied,14–16 and
fidence interval) mm. The artificial tear B group obtained it significantly improved symptoms, such as burning, red-
14.20 ± 8.62 (5–35) score points (t = 2.92, p < 0.01). This ness, photophobia, and foreign body sensation. CLHA was
supposes a small effect size of 0.26. Schirmer increased used previously to analyze the ocular surface properties in
2.46 ± 4.62 (0.74–4.17, 95% confidence interval) mm. dogs17–19 with keratoconjunctivitis sicca, and they demon-
Differences are reported in Figure 2. Post-treatment com- strated the efficacy of CLHA in reducing the clinical signs
parison between the artificial tears revealed no significant associated with dry eye. Fallacara et al.20 reported the in
differences between groups (t = 0.20, p = 0.83), with a dif- vitro re-epithelialization assessment ability of two differ-
ference of 0.43 ± 2.12 (−3.81 to 4.68, 95% confidence ent preparations containing CLHA with urea. They dem-
interval) mm. onstrated, for the first time, hopeful results for the use of
CLHA eyedrops for the management of dry eye symptoms
and corneal injuries in human eyes. To our knowledge, the
Tear breakup time test (TBUT)
first in vivo study in humans was performed by Cagini
In relation to the tear quality, the artificial tear A group et al.11 who compared the stability of the tear film after the
obtained 8.30 ± 2.08 (4–12) s (t = 15.50, p < 0.01). This instillation of eye drops containing HA or CLHA in
supposes a large effect size of 2.49. The TBUT increased patients with Sjögren’s dry eye. Their methodology stud-
by 4.26 ± 1.50 (3.70–4.80, 95% confidence interval) s. ied tear stability only during the first sixty minutes after
The artificial tear B group obtained 7.23 ± 2.40 (4–12) s instillation and reported that CLHA eyedrops obtained bet-
(t = 8.79, p < 0.01). This supposes a large effect size of ter tear stability than uncrosslinked HA. These results are
1.49. The TBUT increased by 2.96 ± 1.84 (2.27–3.65, consistent with the TBUT results of our study.
95% confidence interval) s. Differences are reported in All of the patients in our study experienced less dry eye
Figure 3. Post-treatment comparisons between the artifi- symptoms after treatment and obtained better results on
cial tears revealed that group A obtained better results with OSDI, TBUT and Schirmer I tests. The amelioration was
a difference of 1.06 ± 0.58 (0.10–2.23, 95% confidence larger in group A, who received cross-linked hyaluronic
interval) score points (t = 1.83, p < 0.05). acid, compared to group B, who received carmellose,
even with the higher total daily dose used in group B. Tear
A OSDI decreased 16.33 ± 7.61 score points while Tear B
Discussion
OSDI decreased 11.74 ± 8.46, this supposed a statistically
This prospective, double-blind, single-center study com- significant difference between both groups of 4.59 ± 2.07
pared the efficacy of crosslinked hyaluronic acid with score points (t = 2.21, p < 0.05). Tear A TBUT increased
coenzyme Q10 and vitamin E against carmellose eyedrops 4.26 ± 1.50 s while Tear B TBUT increased 2.96 ± 1.84 s,
in dry eye patients under antidepressant or anxiolytics this supposed a statistically significant difference between
treatment during a two-month management period. Lower both groups of 1.30 ± 0.43 s (t = 2.98, p < 0.01). Tear A
total daily dose of CLHA obtained same results in some Schirmer increased 1.06 ± 6.62 mm while Tear B Schirmer
Serrano-Morales et al. 5

increased 2.46 ± 4.62 mm, this supposed a non-statisti- Funding

cally significant difference between both groups of The author(s) received no financial support for the research,
1.40 ± 1.47 mm (t = −.95, p = 0.34). Cross-linked hyalu- authorship, and/or publication of this article.
ronic acid contributes to a better lubrication effect than
carmellose due to the reticulated structure, which forms a ORCID iD
liquid matrix on the ocular surface. This matrix includes
José-María Sánchez-González https://orcid.org/0000-0003-
coenzyme Q10 molecules and vitamin E, which exert
0450-7717
antioxidant effects that contribute to the epithelial ocular
surface repair. Only two drops of artificial tears with
cross-linked hyaluronic acid with coenzyme Q10 and References
vitamin E is sufficient to ameliorate postsurgical recuper- 1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II
ation after cataracts surgery.21 definition and classification report. Ocul Surf 2017; 15(3):
Crosslinked hyaluronic acid eyedrops with coenzyme 276–283.
Q10 and vitamin E are scarcely studied. Postorino et al.12 2. Mizoguchi S, Iwanishi H, Arita R, et al. Ocular surface
compared these artificial tears versus lineal hyaluronic inflammation impairs structure and function of meibomian
gland. Exp Eye Res 2017; 163: 78–84.
acid, but these patients were not under pharmacological
3. Stern ME, Gao J, Siemasko KF, et al. The role of the lacri-
treatments that contributed to eye dryness, as in our study. mal functional unit in the pathophysiology of dry eye. Exp
Crosslinked and lineal hyaluronic acid tears were also Eye Res 2004; 78(3): 409–416.
used at the same total daily dose in Postorino’s study, but 4. Thulasi P and Djalilian AR. Update in current diagnostics
we administered a higher total daily dose of carmellose and therapeutics of dry eye disease. Ophthalmology 2017;
compared to crosslinked hyaluronic acid. Despite the dif- 124(11S): S27–S33.
ferences between both studies, crosslinked hyaluronic 5. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II
acid showed better efficacy in dry eye management. A epidemiology report. Ocul Surf 2017; 15(3): 334–365.
recent review by Posarelli et al.22 found that the current 6. Sriprasert I, Warren DW, Mircheff AK, et al. Dry eye in
pharmacological trend is improving the properties of hya- postmenopausal women. Menopause 2016; 23(3): 343–351.
luronic acid via crosslinking parts of the molecule to 7. Koçer E, Koçer A, Özsütçü M, et al. Dry eye related to com-
monly used new antidepressants. J Clin Psychopharmacol
achieve better bioavailability and resistance to degrada-
2015; 35(4): 411–413.
tion. These studies conclude that CLHA as a tear supple- 8. Fraunfelder FT, Sciubba JJ and Mathers WD. The role of
ment provides better ocular comfort than linear hyaluronic medications in causing dry eye. J Ophthalmol 2012; 2012:
acid in dry eye disease, and it is the subject of growing 285851.
interest and discussion. 9. Jones L, Downie LE, Korb D, et al. TFOS DEWS II man-
Previous authors have similar results with crosslinked agement and therapy report. Ocul Surf 2017; 15(3): 575–
hyaluronic acid in dry eye disease against non-crosslinked 628.
hyaluronic acid or against other artificial tears such car- 10. Aragona P, Di Stefano G, Ferreri F, et al. Sodium hyaluro-
mellose. However, among the strengths, this is, to best of nate eye drops of different osmolarity for the treatment of
our knowledge the first to report these findings in meno- dry eye in Sjögren’s syndrome patients. Br J Ophthalmol
pause women receiving antidepressant or anxiolytic 2002; 86(8): 879–884.
11. Cagini C, Torroni G, Fiore T, et al. Tear film stability in
treatment. Regarding the limitations, sample size could
Sjögren syndrome patients treated with hyaluronic acid
be higher and other variables, such osmolarity test could versus crosslinked hyaluronic acid-based eye drops. J Ocul
increase outcomes reliability. Pharmacol Ther 2017; 33(7): 539–542.
Lower total daily dose of crosslinked hyaluronic acid 12. Postorino EI, Rania L, Aragona E, et al. Efficacy of eye-
eyedrops obtained similar efficacy results in terms of tear drops containing cross-linked hyaluronic acid and coen-
stability and subjective dry eye sensation than higher car- zyme Q10 in treating patients with mild to moderate dry
mellose total daily dose. The CLHA group demonstrated eye. Eur J Ophthalmol 2018; 28(1): 25–31.
that a lower total daily dose was sufficient to achieve better 13. Cohen J. Statistical power analysis for the behavorial sci-
dry eye disease management compared to carmellose. This ences. 2nd ed. New York: Lawrence Erlbaum Associates
difference was due to the longer permanence time of the Publishers, 1988.
tears on the ocular surface of the crosslinked hyaluronic 14. Szegedi S, Scheschy U, Schmidl D, et al. Effect of single
instillation of two hyaluronic acid-based topical lubricants
acid and the repairing effects of the antioxidants.
on tear film thickness in patients with dry eye syndrome. J
Ocul Pharmacol Ther 2018; 34(9): 605–611.
Declaration of conflicting interests 15. Carracedo G, Pastrana C, Serramito M, et al. Evaluation
The author(s) declared no potential conflicts of interest with of tear meniscus by optical coherence tomography after
respect to the research, authorship, and/or publication of this different sodium hyaluronate eyedrops instillation. Acta
article. Ophthalmol 2019; 97(2): e162–e169.
6 European Journal of Ophthalmology 00(0)

16. Fondi K, Wozniak PA, Schmidl D, et al. Effect of hyalu- companion animals. Investig Opthalmology Vis Sci 2017;
ronic acid/trehalose in two different formulations on signs 58(11): 4616–4622.
and symptoms in patients with moderate to severe dry eye 20. Fallacara A, Vertuani S, Panozzo G, et al. Novel artificial
disease. J Ophthalmol 2018; 2018: 4691417. tears containing cross-linked hyaluronic acid: an in vitro re-
17. Williams DL and Mann BK. Efficacy of a crosslinked hya- epithelialization study. Molecules 2017; 22(12): 2104.
luronic acid-based hydrogel as a tear film supplement: a 2 1. Fogagnolo P, Sacchi M, Ceresara G, et al. The effects of
masked controlled study. PLoS One 2014; 9(6): e99766. topical Coenzyme Q 10 and Vitamin E D-a-Tocopheryl
18. Williams DL and Mann BK. A crosslinked HA-based hydro- polyethylene glycol 1000 succinate after cataract surgery: a
gel ameliorates dry eye symptoms in dogs. Int J Biomater clinical and in vivo confocal study. Ophthalmologica 2013;
2013; 2013: 460437. 229(1): 26–31.
19. Williams DL, Wirostko BM, Gum G, et al. Topical cross- 22. Posarelli C, Passani A, Del Re M, et al. Cross-linked hya-
linked HA-based hydrogel accelerates closure of cor- luronic acid as tear film substitute. J Ocul Pharmacol Ther
neal epithelial defects and repair of stromal ulceration in 2019; 35(7): 381–387.