Clinical Effects and Safety of 3% Diquafosol After Cataract Surgery

• Sponsor: Soonchunhyang University Hospital (Other)
• Overall Status: Completed
• CT.gov ID: NCT02608489
• Collaborator: (none)
• Enrollment: 86
• Arms: 2
• Duration (Months): 12

Study Details

Study Description

Brief Summary

The purpose of this study is determine whether 3% diquafosol and 0.1% sodium hyaluronate are effective and safe in the treatment of patients with dry eye after cataract surgery.

Condition or Disease	Intervention/Treatment	Phase
Dry Eye Syndromes	Drug: Diquafosol (Diquas); Drug: Sodium Hyaluronate (Hyalein)	N/A

Detailed Description

Study group and protocol: This was a prospective open-label randomized study. All patients were given a full explanation of the study, and written informed consent was obtained from all participants. The study protocol adhered to the tenets of the Declaration of Helsinki. The Institutional Review Board and Ethics Committee, Soonchunhyang University Seoul Hospital, approved this study (SCHUH 2013-12-012). Patients were randomly allocated into the diquafosol group (D group) or the hyaluronate group (H group) using a simple unrestricted randomization method by the controller. The D group used 3% diquafosol tetrasodium ophthalmic solution (Diquas®; Santen Pharmaceutical Co., Ltd., Osaka, Japan) six times a day and the H group used 0.1% sodium hyaluronate ophthalmic solution (Hyalein®; Santen Pharmaceutical Co., Ltd., Osaka, Japan) six times a day. Both groups instilled each eye drop from postoperative day 1 to postoperative week 12.

Participants: Consecutive patients aged 20-90 years with bilateral or unilateral cataract undergoing uncomplicated phacoemulsification and intraocular lens (IOL) implantation at Soonchunhyang University Hospital between January 2014 and January 2015 were enrolled. The inclusion criteria were patients with mild to moderate dry eye (level 1 or 2) based on the dry eye severity scale adopted by the Dry Eye Workshop (DEWS) report and who used only artificial tears occasionally1, and patients without or with mild blepharitis.18 The exclusion criteria were presence of any complications after cataract surgery such as cystoid macular edema, patients using any topical eye drops on a regular basis, treatment history of dry eye beyond artificial tears, any ocular surgery within the prior 6 months, contact lens wear, serious ocular surface disease (e.g., Sjögren's syndrome, ocular pemphigoid, conjunctival scarring, chemical injury), lacrimal or eyelid disease (e.g., moderate to severe blepharitis18), use of concomitant medications that could cause dry eye (e.g., antihistamines, antidepressants, decongestants, anticholinergic drugs), and allergy to any of the study medications.

Objective and subjective clinical assessments of dry eye: All patients underwent ophthalmic examinations preoperatively and postoperatively in the order of following : uncorrected distant visual acuity (UDVA) test, an ocular surface disease index (OSDI) questionnaire, Schirmer I test without anesthesia, changes in HOAs after blinking, tear break-up time (TBUT), corneal fluorescein staining, and lissamine green (LG) conjunctival staining. Eyelid and anterior chamber cells were evaluated by slit-lamp biomicroscopy to assess the presence of blepharitis/meibomian gland plugging and intraocular inflammation. Routine postoperative examinations were scheduled for 1 week, 4 weeks, and 12 weeks after surgery.

Efficacy and safety evaluation: To evaluate the efficacy of the two different eye drops, we compared each measurement between the two groups throughout the study period, and at each follow-up, and also compared the patterns of changes in each group to identify which group recovered earlier. we evaluated the safety of the two eye drops, including anterior chamber inflammation and discontinuation of the eye drops due to drug-related discomfort. Patients that had any adverse events or wanted to stop using the eye drops were excluded from the study, but these patients were included in the safety evaluation.

Surgical procedure: A 2.8 mm clear corneal incision was made at the location of the steep corneal astigmatism axis. A standard phacoemulsification technique was used with topical anesthesia with 2% lidocaine. A foldable IOL was implanted into the capsular bag. There was no suture at the corneal incision site. Patients received moxifloxacin (Vigamox; Alcon, Fort Worth, TX), which is a preservative-free formulation, and rimexolone (Vexol; Alcon), which contains 0.01% BAK, four times a day after surgery for 4 weeks.

Statistical analysis: For statistical analysis, UDVA was converted from Snellen into logMAR values. Baseline data were compared between the groups using the Mann-Whitney U-test, Fisher's exact test, and the linear mixed model after adjusting for inter-eye correlations, age, and sex. In addition, another mixed model was used to compare measurement data between the two groups by considering the correlation between both eyes of each patient at each follow-up. To obtain an overall comparison between treatment responses throughout the study period considering the two levels of correlation in subjects and follow-up, a bivariate generalized linear mixed (GLM) model with asymmetric random effects was used. In the last step, a bivariate GLM model was also used to identify the patterns of changes in measured data throughout the study period. The intergroup differences in adverse events were analyzed using Fisher's exact test. SPSS software (version 21, SPSS, Inc., Chicago, IL) was used for all statistical analyses, and P < .05 was taken to indicate statistical significance.

Study Design

• Study Type: Interventional
• Actual Enrollment: 86 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Clinical Effects and Safety of 3% Diquafosol Ophthalmic Solution for Patients With Dry Eye After Cataract Surgery: A Randomized Controlled Trial
• Study Start Date: Jan 1, 2014
• Actual Primary Completion Date: Jan 1, 2015
• Actual Study Completion Date: Jan 1, 2015

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Diqufosol 3% Diquafosol Tetrasodium Ophthalmic Solution	Drug: Diquafosol (Diquas); Diquafosol group used diquafosol 6 times a day during study period.
Placebo Comparator: Hyaluronate 0.1% Sodium Hyaluronate Ophthalmic Solution	Drug: Sodium Hyaluronate (Hyalein); Hyaluronate group used sodium hyaluronate 6 times a day during study period.

Outcome Measures

Primary Outcome Measures

1. an Ocular Surface Disease Index (OSDI) Questionnaire That is Related to Dry Eye Severity. [12 weeks]

   The OSDI questionnaire consists of 12 questions that evaluate subjective symptoms related to dry eye and vision The score ranges were between 0 and 100 scores and the higher scores represent a worse outcome.

2. Schirmer I Test Without Anesthesia That is Related to Dry Eye Severity. [12 weeks]

   Schirmer paper strips were placed into the temporal one third of the lower conjunctival sac for 5 min and the wetness on the strips was measured.

3. Changes in HOAs After Blinking That is Related to Dry Eye Severity. [12 weeks]

   Corneal HOAs and serial measurement of ocular total HOAs were evaluated using a KR-1W wavefront analyzer (Topcon Medical System, Inc., Tokyo, Japan). Serial measurement of total ocular HOAs was measured every second for 10 s after complete blinking in continuous measurement mode. The difference between the fifth and first HOA was used to evaluate the tear film instability.

4. Tear Break-up Time (TBUT) That is Related to Dry Eye Severity. [12 weeks]

   TBUT was assessed by instillation of a drop of 2% sterile fluorescein into the conjunctival sac and recording the interval between the last complete blink and the first appearance of a dry spot or disruption of the tear film.

5. Corneal Fluorescein Staining That is Related to Dry Eye Severity. [12 weeks]

   Ocular surface damage was assessed by the National Eye Institute (NEI) workshop grading system, and corneal fluorescein staining was evaluated. Instillation of fluorescein in both eyes. After 1 or 2 full blinks, the intensity of staining of both cornea was scored. According to the National Eye Institute (NEI) workshop grading system, the cornea was divided into five sections. The minimum staining score was 0 and the maximum staining score was 15 points (up to 3 points for each section). 0 : best score (no corneal damage) 15 : worst score (severe corneal damages)

6. Lissamine Green (LG) Conjunctival Staining That is Related to Dry Eye Severity [12 weeks]

   Ocular surface damage was assessed by the National Eye Institute (NEI) workshop grading system, and conjunctival LG staining were evaluated. Instillation of 1% lissamine green in both eyes. After 1 or 2 full blinks, the intensity of staining of both medial and lateral bulbar conjunctiva was cored. According to the National Eye Institute (NEI) workshop grading system, the conjunctiva was divided into six sections. The minimum staining score was 0 and the maximum staining score was 18 points (up to 3 points for each section). 0 : best score (no conjunctival damage) 18 : worst score (severe conjunctival damages)

Secondary Outcome Measures

1. Grades of Anterior Chamber Cells. [12 weeks]

   Anterior chamber inflammation was examined with a slit-lamp clinically, and divided into six grades using the Standardization of Uveitis Nomenclature (SUN) working group grading scheme. grade 0 : <1 cell in field, grade 0.5 : 1-5 cells in field, grade 1 : 6-15 cells in field, grade 2 : 16-25 cells in field grade 3 : 26-50 cells in field, grade 4 : >50 cells in field Field size is a 1 mm X 1 mm slit beam

2. Number of Participants Who Stop Using the Eye Drops Due to Drug-related Discomfort [12 weeks]

   Drug-related discomfort is defined as having started after eye drop instillation and lasting several minutes, occurring every time during instillation at any time up to 12 weeks into the follow-up period. Patients that had any adverse events or wanted to stop using the eye drops were excluded from the study, but these patients were included in the safety evaluation.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 20 Years to 90 Years
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Bilateral or unilateral cataract undergoing phacoemulsification and intraocular lens (IOL) implantation at Soonchunhyang University Hospital between January 2014 and January 2015

• Patients with mild to moderate dry eye (level 1 or 2) based on the dry eye severity scale adopted by the Dry Eye Workshop (DEWS) report and who used only artificial tears occasionally

Exclusion Criteria:

• Presence of any complications after cataract surgery such as cystoid macular edema

• Patients using any topical eye drops on a regular basis

• Treatment history of dry eye beyond artificial tears

• Any ocular surgery within the prior 6 months

• Contact lens wear

• Serious ocular surface disease (e.g., Sjögren's syndrome, ocular pemphigoid, conjunctival scarring, chemical injury)

• Eyelid or lacrimal disease

• Use of concomitant medications that could cause dry eye and allergy to any of the study medications

Contacts and Locations

Locations

No locations specified.

Sponsors and Collaborators

• Soonchunhyang University Hospital

Investigators

• Principal Investigator: Jin Kwon Chung, MD, Soonchunhyang University Hospital

Study Documents (Full-Text)

None provided.

More Information

Publications

None provided.

• Responsible Party: Jin Kwon Chung, Assistant Professor, Cornea & Refractive Surgery Service, Department of Ophthalmology, Soonchunhyang University Hospital
• ClinicalTrials.gov Identifier: NCT02608489
• Other Study ID Numbers: SCHUH 2013-12-012
• First Posted: Nov 18, 2015
• Last Update Posted: Oct 17, 2016
• Last Verified: Aug 1, 2016

• Additional relevant MeSH terms: Cataract; Dry Eye Syndromes; Keratoconjunctivitis Sicca; Capsule Opacification; Hyaluronic Acid

Study Results

Participant Flow

Recruitment Details	Consecutive patients aged 20-90 years with bilateral or unilateral cataract undergoing uncomplicated phacoemulsification and intraocular lens (IOL) implantation at Soonchunhyang University Hospital between January 1, 2014 and January 31, 2015 were enrolled.

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Period Title: Overall Study
STARTED	43	43
COMPLETED	30	33
NOT COMPLETED	13	10

Baseline Characteristics

Arm/Group Title	Diqufosol	Hyaluronate	Total
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.	Total of all reporting groups
Overall Participants	30	33	63
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	65.53 (11.15)	65.37 (10.02)	65.45 (10.62)
Sex: Female, Male (Count of Participants)
Female	18 60%	24 72.7%	42 66.7%
Male	12 40%	9 27.3%	21 33.3%
Obstructive Meibomian Gland Dysfunction (MGD) (participants) [Number]
None	17 56.7%	19 57.6%	36 57.1%
Mild	13 43.3%	14 42.4%	27 42.9%
Ocular Surface Disease Index ± SD (Scores on a scale) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [Scores on a scale]	22.23 (14.65)	23.64 (16.62)	22.96 (15.11)
tear Break-Up Time ± SD (seconds) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [seconds]	4.88 (2.52)	4.54 (1.85)	4.70 (2.06)
Schirmer test ± SD (mm) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [mm]	3.52 (4.13)	3.67 (2.88)	3.58 (3.31)
Fluorescein staining score ± SD (score) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [score]	1.62 (1.77)	1.77 (1.73)	1.69 (1.75)
Lissamine green staining score ± SD (score) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [score]	1.55 (1.19)	1.94 (1.56)	1.79 (1.38)
Total High Order Aberration (HOA) changes ± SD (microns) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [microns]	0.042 (0.041)	0.041 (0.048)	0.041 (0.045)
Uncorrected visual acuity (LogMAR) ± SD (logMAR) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [logMAR]	0.80 (0.52)	0.77 (0.45)	0.78 (0.47)
Grade of anterior chamber cells (grade) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [grade]	0 (0)	0 (0)	0 (0)

Outcome Measures

1. Primary Outcome

Title	an Ocular Surface Disease Index (OSDI) Questionnaire That is Related to Dry Eye Severity.
Description	The OSDI questionnaire consists of 12 questions that evaluate subjective symptoms related to dry eye and vision The score ranges were between 0 and 100 scores and the higher scores represent a worse outcome.
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure Eyes	45	49
Baseline	21.09 (3.86)	23.00 (2.66)
Postoperative week 1	31.28 (5.49)	20.31 (4.63)
Postoperative week 4	20.31 (4.63)	23.00 (3.19)
Postoperative week 12	9.76 (7.95)	16.92 (13.11)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.221
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 12 follow-up.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.015
	Comments
	Method	Mixed Models Analysis
	Comments

2. Primary Outcome

Title	Schirmer I Test Without Anesthesia That is Related to Dry Eye Severity.
Description	Schirmer paper strips were placed into the temporal one third of the lower conjunctival sac for 5 min and the wetness on the strips was measured.
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	3.61 (0.84)	3.69 (0.58)
Postoperative week 1	2.03 (0.37)	1.76 (0.25)
Postoperative week 4	3.22 (0.62)	2.59 (0.43)
Postoperative week 12	4.10 (2.87)	2.52 (2.08)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.256
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at Postoperative week 12 follow-up.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.025
	Comments
	Method	Mixed Models Analysis
	Comments

3. Primary Outcome

Title	Changes in HOAs After Blinking That is Related to Dry Eye Severity.
Description	Corneal HOAs and serial measurement of ocular total HOAs were evaluated using a KR-1W wavefront analyzer (Topcon Medical System, Inc., Tokyo, Japan). Serial measurement of total ocular HOAs was measured every second for 10 s after complete blinking in continuous measurement mode. The difference between the fifth and first HOA was used to evaluate the tear film instability.
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	0.042 (0.010)	0.041 (0.007)
Postoperative week 1	0.153 (0.057)	0.260 (0.040)
Postoperative week 4	0.067 (0.029)	0.074 (0.043)
Postoperative week 12	0.034 (0.040)	0.039 (0.147)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.080
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 12 follow-up.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.021
	Comments
	Method	Mixed Models Analysis
	Comments

4. Primary Outcome

Title	Tear Break-up Time (TBUT) That is Related to Dry Eye Severity.
Description	TBUT was assessed by instillation of a drop of 2% sterile fluorescein into the conjunctival sac and recording the interval between the last complete blink and the first appearance of a dry spot or disruption of the tear film.
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	4.98 (0.53)	4.50 (0.36)
Postoperative week 1	3.50 (1.35)	3.00 (1.16)
Postoperative week 4	5.64 (1.89)	3.96 (1.46)
Postoperative week 12	6.69 (2.23)	4.38 (1.92)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	<0.001
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 4
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	<0.001
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 3

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 12
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	<0.001
	Comments
	Method	Mixed Models Analysis
	Comments

5. Primary Outcome

Title	Corneal Fluorescein Staining That is Related to Dry Eye Severity.
Description	Ocular surface damage was assessed by the National Eye Institute (NEI) workshop grading system, and corneal fluorescein staining was evaluated. Instillation of fluorescein in both eyes. After 1 or 2 full blinks, the intensity of staining of both cornea was scored. According to the National Eye Institute (NEI) workshop grading system, the cornea was divided into five sections. The minimum staining score was 0 and the maximum staining score was 15 points (up to 3 points for each section). 0 : best score (no corneal damage) 15 : worst score (severe corneal damages)
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	1.52 (0.41)	1.78 (0.28)
Postoperative week 1	2.09 (0.45)	2.88 (0.31)
Postoperative week 4	1.09 (0.33)	1.73 (0.23)
Postoperative week 12	0.48 (0.77)	1.21 (1.45)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.045
	Comments
	Method	Mixed Models Analysis
	Comments

6. Primary Outcome

Title	Lissamine Green (LG) Conjunctival Staining That is Related to Dry Eye Severity
Description	Ocular surface damage was assessed by the National Eye Institute (NEI) workshop grading system, and conjunctival LG staining were evaluated. Instillation of 1% lissamine green in both eyes. After 1 or 2 full blinks, the intensity of staining of both medial and lateral bulbar conjunctiva was cored. According to the National Eye Institute (NEI) workshop grading system, the conjunctiva was divided into six sections. The minimum staining score was 0 and the maximum staining score was 18 points (up to 3 points for each section). 0 : best score (no conjunctival damage) 18 : worst score (severe conjunctival damages)
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	1.40 (0.32)	1.91 (0.22)
Postoperative week 1	2.56 (0.73)	3.86 (0.50)
Postoperative week 4	0.86 (1.18)	2.31 (2.12)
Postoperative week 12	0.36 (0.76)	1.33 (2.04)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.001
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 4
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.002
	Comments
	Method	Mixed Models Analysis
	Comments

Statistical Analysis 3

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	Linear mixed model was used to compare measurement data between the 2 groups by considering the correlation between both eyes of each patient at postoperative week 12
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.034
	Comments
	Method	Mixed Models Analysis
	Comments

7. Secondary Outcome

Title	Grades of Anterior Chamber Cells.
Description	Anterior chamber inflammation was examined with a slit-lamp clinically, and divided into six grades using the Standardization of Uveitis Nomenclature (SUN) working group grading scheme. grade 0 : <1 cell in field, grade 0.5 : 1-5 cells in field, grade 1 : 6-15 cells in field, grade 2 : 16-25 cells in field grade 3 : 26-50 cells in field, grade 4 : >50 cells in field Field size is a 1 mm X 1 mm slit beam
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	30	33
Measure eyes	45	49
Baseline	0 (0)	0 (0)
Postoperative week 1	1.54 (0.34)	1.78 (0.25)
Postoperative week 4	0.16 (0.26)	0.36 (0.22)
Postoperative week 12	0 (0)	0 (0)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Diqufosol, Hyaluronate
	Comments	To obtain an overall comparison between treatment responses throughout the study period considering the 2 levels of correlation in subjects and follow-up, a linear mixed model with asymmetric random effects was used.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.151
	Comments
	Method	Mixed Models Analysis
	Comments

8. Secondary Outcome

Title	Number of Participants Who Stop Using the Eye Drops Due to Drug-related Discomfort
Description	Drug-related discomfort is defined as having started after eye drop instillation and lasting several minutes, occurring every time during instillation at any time up to 12 weeks into the follow-up period. Patients that had any adverse events or wanted to stop using the eye drops were excluded from the study, but these patients were included in the safety evaluation.
Time Frame	12 weeks

Outcome Measure Data

Analysis Population Description

Overall, 1 of 31 patients (3.22%), a 64-year-old man who underwent bilateral sequential same-day cataract surgery, stopped using the study eye drops owing to severe irritation in the D group.

Arm/Group Title	Diqufosol	Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.	0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
Measure Participants	31	33
Number [participants]	1 3.3%	0 0%

Adverse Events

Time Frame	12 weeks
Adverse Event Reporting Description	Patients that had any adverse events or wanted to stop using the eye drops were excluded from the study, but these patients were included in the safety evaluation.
Arm/Group Title	Diqufosol		Hyaluronate
Arm/Group Description	3% Diquafosol Tetrasodium Ophthalmic Solution Diquafosol (Diquas): Diquafosol group used diquafosol 6 times a day during study period.		0.1% Sodium Hyaluronate Ophthalmic Solution Sodium Hyaluronate (Hyalein): Hyaluronate group used sodium hyaluronate 6 times a day during study period.
All Cause Mortality
	Diqufosol		Hyaluronate
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	/ (NaN)		/ (NaN)
Serious Adverse Events
	Diqufosol		Hyaluronate
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/31 (0%)		0/33 (0%)
Other (Not Including Serious) Adverse Events
	Diqufosol		Hyaluronate
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	1/31 (3.2%)		0/33 (0%)
Eye disorders
Severe irritation	1/31 (3.2%)	1	0/33 (0%)	0

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.