1. Is autologous blood a feasible alternative to autologous serum in the treatment of dry eye secondary to Sjögren’s syndrome? N Nesaratnam, S Shah, B Kumar, J Wawrzynski, J Than, A Sharma References: 1.Yoon, K-C. (2010). Umbilical Cord and Its Blood: A Perspective on Its Current and Potential Use in Ophthalmology. In: Bhattacharya, N., Stubblefield, P. ed. Regenerative Medicine Using Pregnancy-Specific Biological Substances. Springer London, p. 179 2.Vesaluoma, M., Teppo, A.M., Grönhagen-Riska, C., and Tervo, T. (1997). Platelet-derived growth factor-BB (PDGF-BB) in tear fluid: a potential modulator of corneal wound healing following photorefractive keratectomy. Curr. Eye Res. 16, 825–831. 3.Bradley, J.C., Bradley, R.H., McCartney, D.L., and Mannis, M.J. (2008). Serum growth factor analysis in dry eye syndrome. Clin. Experiment. Ophthalmol. 36, 717–720. 4.Matsumoto, Y. (2004). Autologous serum application in the treatment of neurotrophic keratopathy. Ophthalmology 111, 1115–1120. 5.Tsubota, K., Goto, E., Fujita, H., Ono, M., Inoue, H., Saito, I., and Shimmura, S. (1999). Treatment of dry eye by autologous serum application in Sjögren’s syndrome. Br J Ophthalmol 83, 390–395. 6.Hwang, J., Chung, S.-H., Jeon, S., Kwok, S.-K., Park, S.-H., and Kim, M.-S. (2014). Comparison of clinical efficacies of autologous serum eye drops in patients with primary and secondary Sjögren syndrome. Cornea 33, 663–667. 7.Hussain, M., Shtein, R.M., Sugar, A., Soong, H.K., Woodward, M.A., DeLoss, K., and Mian, S.I. (2014). Long-term use of autologous serum 50% eye drops for the treatment of dry eye disease. Cornea 33, 1245–1251. 8.Li, J., Zhang, X., Zheng, Q., Zhu, Y., Wang, H., Ma, H., Jhanji, V., and Chen, W. (2015). Comparative Evaluation of Silicone Hydrogel Contact Lenses and Autologous Serum for Management of Sjögren Syndrome-Associated Dry Eye. Cornea 34, 1072–1078. 9.López-García, J.S., García-Lozano, I., Rivas, L., and Martínez-Garchitorena, J. (2007). [Use of autologous serum in ophthalmic practice]. Arch Soc Esp Oftalmol 82, 9–20. 10.McDonnell, P.J., Schanzlin, D.J., and Rao, N.A. (1988). Immunoglobulin deposition in the cornea after application of autologous serum. Arch. Ophthalmol. 106, 1423–1425. Moorfields at Bedford Hospital The authors declare no relevant commercial relationships. Email: nn252@cam.ac.uk, anant.sharma@bedfordhospital.nhs.uk Introduction In refractory cases of dry eye secondary to Sjögren’s syndrome, where lubricant and anti- inflammatory therapy has failed, autologous serum represents a promising therapy, but despite reported benefits in corneal staining, it remains unclear whether serum confers long-term symptomatic benefit. It also carries significant disadvantages; preparation and storage is expensive and cumbersome. We present an affordable, accessible treatment for dry eye in Sjögren’s syndrome – fingerprick autologous blood. Autologous Serum – lowdown from the literature Mechanism of action of in treatment of dry eye secondary to Sjögren’s syndrome thought to be related to composition of autologous serum closely mimicking that of tears, and possessing growth factors absent in artificial tears (Figure 1) Benefits in dry eye secondary to Sjögren’s syndrome: Reported benefits in both patient symptoms and objective signs of dry eye in Sjögren’s syndrome: Figure 2 – Summary table of use of autologous serum eye drops in the treatment of Sjögren’s syndrome. ✓ Significant improvement compared to baseline (p 0.05) Disadvantages: Cumbersome process of preparation and storage Requires multiple venesections, preparation in well-equipped lab with trained personnel, and freezer storage away from sunlight [5] High concentrations of TGF-β may suppress wound healing [5] Complications: uncommonly, discomfort, bacterial conjunctivitis, or eyelid eczema reported [9], and one case of immunoglobulin deposition in cornea and corneal peripheral infiltrates with use of 100% autologous serum [10] Tears [1] Autologous Serum [3] EGF (ng/ml)1.9-9.70.20 ± 0.06 TGF- β (ng/ml)2-1044.1 ± 14.0 PDGF-BB (pg/ml)95-1330 [2] 2437.4 ± 614.3 Vitamin A (mg/ml)0.4-10.645.5 ± 19.1 Substance P (pg/ml)69.8 ± 24.9157 ± 42.1 [4] IGF-1 (ng/ml)75.7 ± 50.559.7 ± 25.3 NGF (pg/ml)107.5 ± 70.9187.3 ± 50.2 Tsubota et al. [5] (1999) Hwang et al. [6] (2014) Hussain et al. [7] (2014) Li et al. [8] (2015) Number of Patients (Eyes) 12 (24)20 (35)11 (24)18 (35) Concentration of Autologous Serum used 20%50% Length of study4 weeks Mean 11.5 months (range 3 – 33) 6 weeks Patient Symptoms Assessed by face score ✓ Assessed by OSDI and face score ✓ Assessed by OSDI ✗ Assessed by OSDI ✓ Staining Grade ✓✓✓ ✓ Visual Acuity ✗ Schirmer’s I test ✗✗ Tear Break-up Time ✗✓ ✓ Figure 1 – Comparison of growth factor composition of tears, autologous serum and peripheral blood. EGF epidermal growth factor, TGF-β transforming growth factor β, IGF-1 insulin-derived growth factor 1, NGF nerve growth factor Figures 3-6 – Mean corneal staining, ocular comfort index, Schirmer’s test and tear break-up time during 56 days of Fingerprick Autologous Blood (FAB) therapy, and at 4 weeks post-cessation Figure 3Figure 4 Figure 5Figure 6 Methods Patients with Sjögren’s syndrome were instructed to prick a clean finger with a lancet, and apply a drop of blood to the inferior conjunctival fornix 4 times daily for 8 weeks. Follow- up visits occurred at days 4, 14, 28 and 56, and 4 weeks post-cessation. Visual acuity, corneal staining, Schirmer’s test, tear break-up time (TBUT), and ocular comfort index (OCI) were measured. Results were analysed using Student’s paired t-test. Results 8 patients with Sjögren’s syndrome (15 eyes) were recruited. At 8 weeks, there was improvement in Oxford corneal staining grade (4.00 to 2.31 (p=0.0001)), and OCI score (55.63 to 21.00 (p=0.0018)). There was no statistically significant change in mean visual acuity, Schirmer’s and TBUT. 4 weeks post-cessation, staining grade and OCI worsened. There were no complications. Conclusion Our case series suggests autologous blood confers comparable benefit to autologous serum in patients with dry eye secondary to Sjögren’s syndrome, and thus may represent an accessible and affordable alternative treatment.