Finger prick Autologous Blood (FAB) as a novel approach to treatment of non-healing corneal epithelial defects and dry eyes James R Wawrzynski, Jonathan Moore, David Armstrong, Anant Sharma Moorfields eye clinic at Bedford hospital, UK Mater Hospital, Belfast, UK

Finger prick Autologous Blood for treatment of non-healing corneal epithelial defects and dry eyes INTRODUCTION Autologous serum eye drops have been found in controlled trials to be beneficial for patients with severe dry eyes and chronic corneal epithelial defects that are resistant to standard medical therapy. This is likely to be due to the presence of growth factors in the serum such as NGF/CGRP. However, there are logistical and financial difficulties with using autologous serum. (1) Obtaining autologous serum drops requires frequent venesection, which is contraindicated in some patients. (2) The production of autologous serum is an expensive process that is not available as standard on the NHS. There is a risk of significant complications whilst waiting for funding. (3) The serum must be stored by the patient in the freezer / fridge in hundreds of separate bottles. In this study, we investigate whether fresh autologous blood (FAB) obtained by pricking the finger is a safe and effective alternative to autologous serum in the treatment of dry eyes and chronic corneal epithelial defects.

Finger prick Autologous Blood for treatment of non-healing corneal epithelial defects and dry eyes METHODS Four patients with persistent corneal epithelial defects resistant to full conventional medical therapy (including steroids and lubricants drops) were recruited. Three ulcers were secondary to herpes simplex neurotrophic ulceration and the final one was due to chemical trauma. Two further patients with dry eyes ( symptoms and signs) secondary to Sjögren’s syndrome were recruited. Both were resistant to full conventional medical therapy. All patients underwent a comprehensive ocular evaluation including Snellen visual acuity testing and corneal, limbal and conjunctival examination. Dry eye patients alone were asked before commencing treatment to complete an ocular comfort index (OCI) questionnaire Each patient continued with maximal medical therapy and also applied autologous blood to their affected eye(s) four times per day according to the following technique: A fingertip was wiped with an alcohol steret and self-pricked using a standard diabetic lancet. A drop of blood was produced and applied to the lower fornix of the affected eye/s with the lower lid pulled down slightly. Study design: Non-controlled prospective interventional case series.

Finger prick Autologous Blood for treatment of non-healing corneal epithelial defects and dry eyes Instructions for patients:

Corneal fluorescein staining (white) Right eye EXAMPLE OF A DRY EYE PATIENT WITH SJOGRENS Left eye Finger prick Autologous Blood for treatment of non-healing corneal epithelial defects and dry eyes Corneal fluorescein staining (white) Day 0 FAB started OCI Score 55/72 0mm Schirmer 0mm 2sec TBUT 2sec Day 15 on bilateral FAB OCI Score 28/72 5mm Schirmer 2mm 4sec TBUT 4sec Day 57 on bilateral FAB FAB stopped day 57 OCI Score 4/72 2mm Schirmer 1mm 9sec TBUT 13 sec Off FAB for 3 weeks Day 78 OCI Score 34/72 3 sec TBUT 3sec RESULTS Corneal Ulcers: All four ulcers demonstrated complete healing within two weeks of commencing FAB therapy. There was a recurrence of an epithelial defect in one patient with herpetic neurotrophic ulceration following a period of initial re-epithelialisation: This was a case of dense neurotrophia which re-responded positively to increased use of autologous blood. Dry Eyes: Both patients showed substantial improvement such as on OCI questionnaire Tear Break up time ( TBUT) and Schirmer’s test without anaesthetic as shown on the right.

Finger prick Autologous Blood for treatment of non-healing corneal epithelial defects and dry eyes KEY CONCLUSIONS This observational study provides evidence that suggests the use of FAB is a practicable, safe and effective treatment for persistent corneal epithelial defects and dry eyes due to Sjogrens syndrome. The results from this case series suggest that has a beneficial effect like autologous serum without suffering from the significant drawbacks that autologous serum necessarily brings with it. This proof of concept study has resulted in the development of a robust protocol for subsequent recruitment of patients into a multicentre case control study to generate statistical evidence of the potential benefit.