{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T20:37:21Z","timestamp":1788813441762,"version":"build-2803163510"},"reference-count":51,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T00:00:00Z","timestamp":1760572800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Background: This study aimed to evaluate the effects of Trimix\u00ae on the microvilli and glycocalyx of ocular conjunctival epithelial cells, assessing drug persistence on the cell surface and its interaction with the glycocalyx. Microvilli, vital indicators of cellular health, are altered in inflammatory or toxic conditions, making their restoration a key therapeutic target. Method: Building upon previous scanning electron microscopy work, this investigation utilized Transmission Electron Microscopy (TEM) to delve into the direct interaction between Trimix and the cell membrane, elucidating its role in cellular mechanisms. The research involved both an in vitro phase, examining the drug\u2019s molecular arrangement, and an in vivo phase, treating three subjects (healthy, moderate inflammation, severe dry eye) for 30 days. Cytological samples were taken via impression cytology for TEM analysis to observe the drug\u2019s long-term action and its influence on microvillar structures, glycocalyx, and vesicular transport. Results: We demonstrated that Trimix stimulated vesicular transport and promoted the formation of a rudimentary glycocalyx, significantly increasing its presence and the number of microvilli in treated patients across all inflammatory grades, even in severe dry eye. Conclusions: In conclusion, Trimix acts as an effective glycocalyx substitute, restoring the second mucosal system (SMS) and enabling distressed cells to resume essential exchange functions, offering a novel therapeutic approach for dry eye disease.<\/jats:p>","DOI":"10.3390\/life15101611","type":"journal-article","created":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T12:17:02Z","timestamp":1760617022000},"page":"1611","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Evaluation of the Ultrastructural Effects on Conjunctival Epithelial Cells of a New Multiple-Action Artificial Tear Containing Cross-Linked Hyaluronic Acid, Cationic Liposomes, and Trehalose with Transmission Electron Microscopy: A Pilot Study"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6004-7781","authenticated-orcid":false,"given":"Salvatore","family":"Del Prete","sequence":"first","affiliation":[{"name":"Service Biotech s.r.l., 80121 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0540-623X","authenticated-orcid":false,"given":"Daniela","family":"Marasco","sequence":"additional","affiliation":[{"name":"Service Biotech s.r.l., 80121 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9939-0189","authenticated-orcid":false,"given":"Salvatore","family":"Troisi","sequence":"additional","affiliation":[{"name":"Ophthalmologic Unit, Salerno Hospital University, 84100 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3492-014X","authenticated-orcid":false,"given":"Mario","family":"Troisi","sequence":"additional","affiliation":[{"name":"Ophthalmologic Unit, Salerno Hospital University, 84100 Salerno, Italy"},{"name":"Eye Clinic, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4884-0274","authenticated-orcid":false,"given":"Antonio","family":"Del Prete","sequence":"additional","affiliation":[{"name":"Eye Clinic, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Troisi, M., Del Prete, S., Troisi, S., Marasco, D., Rinaldi, M., and Costagliola, C. (2024). Scanning Electron Microscopy (SEM) Evaluation of the Ultrastructural Effects on Conjunctival Epithelial Cells of a New Multiple-Action Artificial Tear Containing Cross-Linked Hyaluronic Acid, Cationic Liposomes and Trehalose. Biomedicines, 12.","DOI":"10.3390\/biomedicines12091945"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1167\/iovs.05-0804","article-title":"Conjunctival Surface Changes in Patients with Sj\u00f6gren\u2019s Syndrome: A Transmission Electron Microscopy Study","volume":"47","author":"Koufakis","year":"2006","journal-title":"Investig. Opthalmol. Vis. Sci."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"416","DOI":"10.1038\/bmt.2011.89","article-title":"Mucosal microvilli in dry eye patients with chronic GVHD","volume":"47","author":"Tatematsu","year":"2012","journal-title":"Bone Marrow Transplant."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"DES157","DOI":"10.1167\/iovs.17-23756","article-title":"The Ocular Surface Glycocalyx and its Alteration in Dry Eye Disease: A Review","volume":"59","author":"Uchino","year":"2018","journal-title":"Investig. Opthalmol. Vis. Sci."},{"key":"ref_5","unstructured":"Rosati, P., Colombo, R., and Maraldi, N. (2004). Istologia, Ermes."},{"key":"ref_6","first-page":"240","article-title":"Dry eye: An inflammatory ocular disease","volume":"9","author":"Hessen","year":"2014","journal-title":"J. Ophthalmic. Vis. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1038\/sj.eye.6702873","article-title":"Impression cytology with scanning electron microscopy: A new method in the study of conjunctival microvilli","volume":"22","author":"Cennamo","year":"2008","journal-title":"Eye"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Grumetto, L., Del Prete, A., Ortosecco, G., Barbato, F., Del Prete, S., Borrelli, A., Schiattarella, A., Mancini, R., and Mancini, A. (2015). Study on the protective Effect of a New Manganese Superoxide Desmutase on the Microvilli of Rabbit eyes exposed to UV radiation. BioMed Res. Int., 2015.","DOI":"10.1155\/2015\/973197"},{"key":"ref_9","first-page":"437","article-title":"Mucin expression and regulation in the ocular surface","volume":"15","author":"Azzam","year":"2017","journal-title":"Ocul. Surf."},{"key":"ref_10","first-page":"105","article-title":"Immunomodulatory role of mucins in the ocular surface","volume":"137","author":"Masli","year":"2015","journal-title":"Exp. Eye Res."},{"key":"ref_11","first-page":"395","article-title":"The ocular surface: The challenge of healing in a dynamic environment","volume":"78","author":"Gipson","year":"2004","journal-title":"Exp. Eye Res."},{"key":"ref_12","first-page":"273","article-title":"Management of the dry eye patient: Evidence-based recommendations","volume":"22","author":"Lemp","year":"2011","journal-title":"Curr. Opin. Ophthalmol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"101845","DOI":"10.1016\/j.clae.2023.101845","article-title":"Efficacy of artificial tears containing trehalose and hyaluronic acid for dry eye disease in women aged 42\u201354 versus \u2265 55 years","volume":"46","author":"Farrant","year":"2023","journal-title":"Cont. Lens Anterior Eye"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"102342","DOI":"10.1016\/j.cis.2020.102342","article-title":"Strategies to prolong the residence time of drug delivery systems on ocular surface","volume":"288","author":"Grassiri","year":"2021","journal-title":"Adv. Colloid Interface Sci."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"114582","DOI":"10.1016\/j.addr.2022.114582","article-title":"Novel drug delivery systems for the management of dry eye","volume":"191","author":"Nagai","year":"2022","journal-title":"Adv. Drug Deliv. Rev."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1080\/17425247.2021.1872542","article-title":"Liposomes as Vehicles for Topical Ophthalmic Drug Delivery and Ocular Surface Protection","volume":"18","year":"2021","journal-title":"Expert. Opin. Drug Deliv."},{"key":"ref_17","first-page":"1921","article-title":"Liposomes Containing Bile Salts as Novel Ocular Delivery Systems for Tacrolimus (FK506): In Vitro Characterization and Improved Corneal Permeation","volume":"8","author":"Dai","year":"2013","journal-title":"Int. J. Nanomed."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1533","DOI":"10.1083\/jcb.147.7.1533","article-title":"Ezrin Promotes Morphogenesis of Apical Microvilli and Basal Infoldings in Retinal Pigment Epithelium","volume":"147","author":"Bonilha","year":"1999","journal-title":"J. Cell Biol."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Chen, X., Wu, J., Lin, X., Wu, X., Yu, X., Wang, B., and Xu, W. (2022). Tacrolimus Loaded Cationic Liposomes for Dry Eye Treatment. Front. Pharmacol., 13.","DOI":"10.3389\/fphar.2022.838168"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.18240\/ijo.2020.09.05","article-title":"Crosslinked hyaluronic acid with liposomes and crocin for management symptoms of dry eye disease caused by moderate meibomian gland dysfunction","volume":"13","year":"2020","journal-title":"Int. J. Ophthalmol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Fallacara, A., Vertuani, S., Panozzo, G., Pecorelli, A., Valacchi, G., and Manfredini, S. (2017). Novel Artificial Tears Containing Cross-Linked Hyaluronic Acid: An In Vitro Re-Epithelialization Study. Molecules, 22.","DOI":"10.3390\/molecules22122104"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Troisi, M., Caruso, C., D\u2019Andrea, L., Rinaldi, M., Piscopo, R., Troisi, S., and Costagliola, C. (2024). Compatibility of a New Ocular Surface Dye with Disposable and Bi-Weekly Soft Contact Lenses: An Experimental Study. Life, 14.","DOI":"10.3390\/life14060653"},{"key":"ref_23","first-page":"113","article-title":"Molecular mechanism of ocular surface damage: Application to an in vitro dry eye model on human corneal epithelium","volume":"17","author":"Meloni","year":"2011","journal-title":"Mol. Vis."},{"key":"ref_24","unstructured":"Liu, L. (2004). Development of a New Lubricant and Nutrient Tear Substitute. [Ph.D. Thesis, Universit\u00e4t zu L\u00fcbeck]."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1038\/eye.1998.105","article-title":"Morphological changes of the conjunctival epithelium in contact lens wearers evaluated by impression cytology","volume":"12","author":"Aragona","year":"1998","journal-title":"Eye"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1136\/bjo.2007.121533","article-title":"Fluorophotometric measurement of the precorneal residence time of topically applied hyaluronic acid","volume":"92","author":"Mochizuki","year":"2008","journal-title":"Br. J. Ophthalmol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1097\/00003226-199207000-00003","article-title":"Ocular surface residence times of artificial tear solutions","volume":"11","author":"Snibson","year":"1992","journal-title":"Cornea"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1097\/OPX.0b013e3181824dc4","article-title":"Effect of viscosity on tear drainage and ocular residence time","volume":"85","author":"Zhu","year":"2008","journal-title":"Optom. Vis. Sci."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Casey-Power, S., Ryan, R., Behl, G., McLoughlin, P., Byrne, M.E., and Fitzhenry, L. (2022). Hyaluronic Acid: Its Versatile Use in Ocular Drug Delivery with a Specific Focus on Hyaluronic Acid-Based Polyelectrolyte Complexes. Pharmaceutics, 14.","DOI":"10.3390\/pharmaceutics14071479"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Guarise, C., Acquasaliente, L., Pasut, G., Pavan, M., Soato, M., Garofolin, G., Beninatto, R., Giacomel, E., Sartori, E., and Galesso, D. (2023). The role of high molecular weight hyaluronic acid in mucoadhesion on an ocular surface model. J. Mech. Behav. Biomed. Mater., 143.","DOI":"10.1016\/j.jmbbm.2023.105908"},{"key":"ref_31","first-page":"188","article-title":"Assessment of the precorneal residence of an ophthalmic ointment in healthy subjects","volume":"35","author":"Greaves","year":"1993","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Troisi, M., Del Prete, S., Troisi, S., Del Prete, A., Bellucci, C., Marasco, D., and Costagliola, C. (2024). The Role of Scanning Electron Microscopy in the Evaluation of Conjunctival Microvilli as an Early Biomarker of Ocular Surface Health: A Literature Review. J. Clin. Med., 13.","DOI":"10.3390\/jcm13247569"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1007\/164_2023_699","article-title":"Characterization of Drug Delivery Systems by Transmission Electron Microscopy","volume":"284","author":"Hoeppener","year":"2024","journal-title":"Handb. Exp. Pharmacol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1002\/med.21981","article-title":"Microscopy based methods for characterization, drug delivery, and understanding the dynamics of nanoparticles","volume":"44","author":"Gupta","year":"2024","journal-title":"Med. Res. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1581","DOI":"10.1007\/s40123-025-01171-6","article-title":"Clinical and Biological Evaluation of NAAGA Versus Azelastine Eye Drops in Patients with Allergic Conjunctivitis and Tear Film Dysfunction: A Randomized Controlled Trial","volume":"14","author":"Troisi","year":"2025","journal-title":"Ophthalmol. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"S53","DOI":"10.1097\/ICL.0000000000000653","article-title":"Disrupted Glycocalyx as a Source of Ocular Surface Biomarkers","volume":"46","year":"2020","journal-title":"Eye Contact Lens."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Mart\u00ednez-Carrasco, R., and Sharma, A. (2025). Ocular surface glycocalyx in health and disease. Front. Cell Dev. Biol., 13.","DOI":"10.3389\/fcell.2025.1561324"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1016\/j.jtos.2021.03.003","article-title":"Membrane-associated mucins of the human ocular surface in health and disease","volume":"21","author":"Fini","year":"2021","journal-title":"Ocul. Surf."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Vitiello, L., Lixi, F., Coco, G., and Giannaccare, G. (2024). Ocular Surface Side Effects of Novel Anticancer Drugs. Cancers, 16.","DOI":"10.3390\/cancers16020344"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Labetoulle, M., Benitez-del-Castillo, J.M., Barabino, S., Herrero Vanrell, R., Daull, P., Garrigue, J.-S., and Rolando, M. (2022). Artificial Tears: Biological Role of Their Ingredients in the Management of Dry Eye Disease. Int. J. Mol. Sci., 23.","DOI":"10.3390\/ijms23052434"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1111\/aos.16629","article-title":"Review of clinical outcomes of a cationic emulsion tear substitute in patients with dry eye disease","volume":"102","author":"Labetoulle","year":"2024","journal-title":"Acta Ophthalmol."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Roszkowska, A.M., Inferrera, L., Spinella, R., Postorino, E.I., Gargano, R., Oliverio, G.W., and Aragona, P. (2022). Clinical Efficacy, Tolerability and Safety of a New Multiple-Action Eyedrop in Subjects with Moderate to Severe Dry Eye. J. Clin. Med., 11.","DOI":"10.3390\/jcm11236975"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1441","DOI":"10.1007\/s40123-022-00518-7","article-title":"Effects of a New Formulation of Multiple-Action Tear Substitute on Objective Ocular Surface Parameters and Ocular Discomfort Symptoms in Patients with Dry Eye Disease","volume":"11","author":"Vigo","year":"2022","journal-title":"Ophthalmol. Ther."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.1007\/s00417-025-06765-1","article-title":"Efficacy and safety of a multi-action tear substitute based on 0.15% cross-linked hyaluronic acid, 3% trehalose and liposomes with stearylamine: A randomized, single-mask, controlled study","volume":"263","author":"Tedesco","year":"2025","journal-title":"Graefes Arch. Clin. Exp. Ophthalmol."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Troisi, M., Del Prete, S., Troisi, S., Marasco, D., and Costagliola, C. (2023). Scanning Electron Microscopy of Conjunctival Scraping: Our Experience in the Diagnosis of Infectious Keratitis with Negative Culture Tests. Reports, 6.","DOI":"10.3390\/reports6010010"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"3358","DOI":"10.3390\/diagnostics13213358","article-title":"Comment on Cabrera-Aguas, M.; Watson, S.L. Updates in Diagnostic Imaging for Infectious Keratitis: A Review.","volume":"13","author":"Troisi","year":"2023","journal-title":"Diagnostics"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Kwon, J., Moghtader, A., Kang, C., Bibak Bejandi, Z., Shahjahan, S., Alzein, A., and Djalilian, A.R. (2025). Overview of Dry Eye Disease for Primary Care Physicians. Medicina, 61.","DOI":"10.3390\/medicina61030460"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"508","DOI":"10.4103\/IJO.IJO_1917_24","article-title":"Preferred practice guidelines and narrative review on infectious keratitis in ocular surface diseases","volume":"73","author":"Aafreen","year":"2025","journal-title":"Indian J. Ophthalmol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"3123","DOI":"10.1007\/s40123-024-01044-4","article-title":"A Preservative-Free Combination of Sodium Hyaluronate and Trehalose Improves Dry Eye Signs and Symptoms and Increases Patient Satisfaction in Real-Life Settings: The TEARS Study","volume":"13","author":"Farrant","year":"2024","journal-title":"Ophthalmol. Ther."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Laihia, J., and Kaarniranta, K. (2020). Trehalose for Ocular Surface Health. Biomolecules, 10.","DOI":"10.3390\/biom10050809"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.1183\/09031936.00136408","article-title":"Small studies: Strengths and limitations","volume":"32","author":"Hackshaw","year":"2008","journal-title":"Eur. Respir. J."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/10\/1611\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T13:07:47Z","timestamp":1760620067000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/10\/1611"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,16]]},"references-count":51,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["life15101611"],"URL":"https:\/\/doi.org\/10.3390\/life15101611","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,16]]}}}