Systemic Comorbidities of Dry Eye Syndrome: The Korean National Health and Nutrition Examination Survey V, 2010 to 2012

Concordance between Self-Reported Visual Difficulty and Objective Visual Impairment: The National Health and Aging Trends Study

PURPOSE

To examine the performance of self-reported visual difficulty (VD) in predicting objective visual impairment (VI) in older adults and explore factors that influence discordance.

DESIGN

Cross-sectional analysis of the National Health and Aging Trends Study (2022).

METHODS

Participants reporting blindness or difficulties with distance or near vision were characterized as having VD. Presenting binocular distance visual acuity (VA), near VA, and contrast sensitivity (CS) were assessed. Objective VI was defined as having VI in distance VA (worse than 20/40), near VA (worse than 20/40), or CS (worse than 1.55 logCS). Receiver operating characteristic analysis was used to compare performance of VD in predicting VI. To investigate factors that influence discordance, we limited our sample to adults with VI and used a multivariable logistic regression model to identify factors associated with not reporting VD. Similar analyses were performed to explore factors associated with reporting VD in adults without VI.

MAIN OUTCOME MEASURES

Discordance factors.

RESULTS

Four thousand nine hundred ninety-nine adults were included in the 2022 cohort. Visual difficulty achieved an area under the curve (AUC) of 56.0 (95% confidence interval [CI], 55.2-56.9) in predicting VI, with a sensitivity of 15.8 (95% CI, 14.2-17.5) and specificity of 96.3 (95% CI, 95.5-96.9). Characteristics associated with not reporting VD in adults with VI included female gender (odds ratio [OR], 0.64 [95% CI, 0.42-0.99]), Hispanic ethnicity (OR, 0.49 [95% CI, 0.31-0.78), higher income (≥75 000, OR, 1.99 [95% CI, 1.14-3.45]), ≥4 comorbidities (OR, 0.46 [95% CI, 0.29-0.72]), and depressive symptoms (OR, 0.49 [95% CI, 0.25-0.93]). Factors associated with self-reporting VD in the absence of VI included Hispanic ethnicity (OR, 2.11 [95% CI, 1.15-3.86]), higher income (≥$75 000, OR, 0.27 [95% CI, 0.12-0.63]), and anxiety symptoms (OR, 3.05 [95% CI, 1.56-5.97]).

CONCLUSIONS

Self-reported VD is a distinct measure assessing disability and has limited ability in predicting objective VI. Caution is advised when using self-reported VD as a surrogate measure for objective VI in epidemiological studies, although it may still be an effective way to capture risk of current or future disability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Association of self-reported psychiatric and systemic risk factors in dry eye disease in adult Korean population

PURPOSE

To evaluate the association between dry eye disease (DED) and various psychiatric and systemic diseases in an adult Korean population aged 40 years or older.

METHODS

Population-based cross-sectional data of 6,732 participants aged ≥40 years was extracted from the Korea National Health and Nutrition Examination Survey 2017-2018 (KNHANES VII). Data including DED, demographic variables, behavioral factors, psychiatric conditions, and systemic diseases was analysed to determine the prevalence and psychiatric and systemic risk factors for DED.

RESULTS

The weighted prevalence of DED was 7.9 ± 0.4% (mean ± SE). Multivariate analysis showed that female sex and urban residence were associated with an increased risk of DED. The prevalence of DED was lower in patients aged ≥70 years than in those aged 40-69 years. Self-reported psychological conditions including perceived stress and depression were associated with the risk of DED. Self-reported Systemic conditions, such as rheumatoid arthritis, degenerative arthritis, osteoporosis, ischemic heart disease, and chronic renal failure had association with an increased risk of DED.

CONCLUSION

DED may be associated with several self-reported psychiatric and systemic conditions, which highlights the need for an integrated approach to manage these diseases for optimal treatment of DED.

Association between dyslipidaemia and dry eye disease: a systematic review and meta-analysis

PURPOSE

To report a systematic review and meta-analysis of the association between dry eye disease (DED) and dyslipidaemia.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were systematically searched from January 2000 to December 2021. We included observational studies to assess the correlation of DED with meibomian gland dysfunction and dyslipidaemia without any language restrictions. The pooled OR with 95% CI was calculated in Stata V.15.

RESULTS

Of 6727 identified studies, 18 studies (21 databases) with a total of 2 663 126 patients were analysed in our meta-analysis. The results showed that DED risk was associated with dyslipidaemia (OR=1.53, 95% CI: 1.41 to 1.66, p=0.001), especially elevated total cholesterol levels (OR=1.57, 95% CI: 1.25 to 1.99, p<0.001), elevated low-density lipoprotein cholesterol levels (OR=1.13, 95% CI: 1.06 to 1.20, p<0.001) and high-density lipoprotein cholesterol levels (OR=1.06, 95% CI: 1.01 to 1.11, p<0.001), but not with serum triglyceride levels. Moreover, having a history of lipid-lowering drug use (OR=1.41, 95% CI: 1.19 to 1.67, p<0.001) was also found to be positively associated with DED risk.

CONCLUSIONS

The findings suggested that dyslipidaemia and lipid-lowering drug use might be associated with an increased risk of DED. More evidence is needed to confirm the findings by prospective studies.

PROSPERO REGISTRATION NUMBER

CRD42022296664.

Relationship between Dry Eye Disease and Dyslipidemia: A Systematic Review

BACKGROUND

Dyslipidemia has been suggested to be associated with the occurrence of dry eye disease (DED). However, whether dyslipidemia is responsible for the development of DED remains unclear. In this systematic review, we explored the relationship between DED and dyslipidemia by using quantitative data.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive literature search in several databases, including PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar, and obtained six relevant studies.

RESULTS

Our findings indicated that the majority of the selected studies reported a statistically significant association between dyslipidemia and DED, particularly in women. However, our quantitative analysis revealed that only two studies reported statistically significant differences in total cholesterol and high-density lipoprotein cholesterol values.

CONCLUSION

No statistically significant differences exist in the majority of lipid profile parameters between individuals with and without DED, but there is a statistically significant association between dyslipidemia and DED.

The relationship between dry eye disease and anticholinergic burden

PURPOSE

Anticholinergic drugs are widely prescribed for many medical conditions. However, data on the association of anticholinergic burden with dry eye disease (DED) are limited. In this study, we aimed to examine the relationship between anticholinergic burden and DED.

METHODS

In this retrospective cohort study, we evaluated a total of 120 participants who underwent ophthalmological examination between February 2021 and February 2022. The drugs used by the patients in the last 2 months were recorded from the institute's electronic data system. Anticholinergic burden was assessed using the Anticholinergic Cognitive Burden (ACB) scale.

RESULTS

The mean age of those patients was 59.0 ± 11.6 years and more than half (n = 33, 64.7%) were women. Patients with DED had significantly higher Charlson comorbidity index scores (p = 0.01), lower Schirmer test values (p = 0.01), higher Ocular Surface Disease Index (OSDI) scores (p = 0.01), and higher anticholinergic burden (p = 0.01). There was a statistically significant positive correlation between ACB and OSDI scores (r = 0.22, p = 0.02) and a negative correlation between ACB scores and Schirmer test values (r = -0.46, p = 0.01). After adjusting for potential confounding factors (age, gender, and comorbidities), each 1-point increase in anticholinergic burden was found to result in a 2.97-fold increase in the risk of DED (OR: 2.97, 95% confidence interval: 1.22-7.24, p = 0.02).

CONCLUSION

Anticholinergic burden appears to be associated with DED. Therefore, greater caution in prescribing anticholinergic drugs for adult patients may be important in reducing the rates of many adverse outcomes.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

A Multicenter, Randomized, Double-Blind Evaluation of the Efficacy of TJO-087 Versus 0.05% Cyclosporine A in Moderate to Severe Dry Eye

Purpose: To compare the efficacy and ocular tolerability of a 0.08% nanoemulsion cyclosporine A (CsA) (TJO-087) once daily versus a conventional 0.05% emulsion CsA twice daily in dry eye disease. Methods: 178 patients with dry eye disease were randomly assigned to one of two groups: the TJO-087 or CsA0.05% group. Changes in the Ocular Surface Disease Index (OSDI), tear film break-up time (TBUT), corneal and conjunctival staining scores, and Schirmer test scores from baseline to the 32-week visit were compared between both groups. To evaluate ocular tolerability of the study formulations, 7 symptoms (stinging/burning, itching, blurred vision, sandiness/grittiness, dryness, light sensitivity, and pain or soreness) were evaluated (the higher the score, the lower the tolerability) at each follow-up visit. Results: A total of 155 eyes of 155 patients were enrolled. The TJO-087 and CsA0.05% groups showed significant improvement in OSDI, TBUT, ocular surface staining, and Schirmer test scores at 32 weeks from baseline. There was no difference in the extent of improvement in all efficacy parameters. There were no differences in the ocular tolerability scores between the 2 groups at all visits, except that the itching score was higher in the TJO-087 group than in the CsA0.05% group at week 8. Conclusions: Using topical 0.08% CsA once daily is an effective therapeutic option for improving the symptoms and signs in dry eye disease, with a tolerability comparable with that of conventional 0.05% CsA. This trial was registered at the US National Library of Medicine ClinicalTrials.gov (http://clinicaltrial.gov) as NCT05245604 (registration date: 19/06/2020).

Impact of aging on the pathophysiology of dry eye disease: A systematic review and meta-analysis

PURPOSE

Dry eye disease (DED) is a common age-related ocular surface disease. However, it is unknown how aging influences the ocular surface microenvironment. This systematic review aims to investigate how the aging process changes the ocular surface microenvironment and impacts the development of DED.

METHODS

An article search was performed in PubMed, EMBASE, and Web of Science. 44 studies reporting on age-related ocular changes and 14 large epidemiological studies involving the prevalence of DED were identified. 8 out of 14 epidemiological studies were further analyzed with meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. Study-specific estimates (impact of aging on the prevalence of DED) were combined using one-group meta-analysis in a random-effects model.

RESULTS

Meta-analysis revealed the prevalence of DED in the elderly aged 60 years old or older was 5519 of 60107 (9.2%) and the odds ratio of aging compared to younger age was 1.313 (95% confidence interval [CI]; 1.107, 1.557). With increasing age, the integrity of the ocular surface and tear film stability decreased. Various inflammatory cells, including senescent-associated T-cells, infiltrated the ocular surface epithelium, lacrimal gland, and meibomian gland, accompanied by senescence-related changes, including accumulation of 8-OHdG and lipofuscin-like inclusions, increased expression of p53 and apoptosis-related genes, and decreased Ki67 positive cells.

CONCLUSIONS

The aging process greatly impacts the ocular surface microenvironment, consequently leading to DED.

Prevalence and Risk Factors of Dry Eye Symptoms after Successful Dacryocystorhinostomy for Patients with Lacrimal Passage Obstruction

PURPOSE

To investigate the prevalence of dry eye symptoms after successful dacryocystorhinostomy and explore the potential risk factors. Methods: This cross-sectional study included 565 patients with lacrimal passage obstruction (LPO) who underwent external dacryocystorhinostomy. Ocular Surface Disease Index (OSDI) total score of 13 or more was regarded as presence of dry eye symptoms. OSDI total score greater than 22 combined with self-reported dry eye was defined as symptomatic dry eye. Logistic regression and linear regression were used to examine the associations between OSDI scores and its potentially predictive factors. Results: Of the 565 patients, 344 completed the questionnaire, among which 101(29.4%) patients presented with dry eye symptoms, including 53(15.4%) mild, 14(4.1%) moderate and 34(9.9%) severe, and 48(14.0%) patients can be defined as symptomatic dry eye. Univariate logistic regression revealed that age, educational levels, income levels, and hypertension were significantly correlated with the presence of dry eye symptoms (P < 0.05). After multivariate adjustment, lower income levels were found significantly associated with dry eye symptoms (P < 0.05). Univariate linear regression demonstrated that age, lower educational levels, surgery history, and hypertension were significantly associated with OSDI total score (P = 0.037, 0.012, 0.022, 0.029 respectively). Multivariate stepwise linear regression manifested that educational levels and the surgery history influenced the OSDI total score mostly (P = 0.021, 0.036 respectively). Conclusions: Dry eye problem of LPO patients after successful dacryocystorhinostomy cannot be ignored. In the preoperative evaluation, we should pay special attention to the elderly patients with lower educational levels, lower income levels or systemic diseases.

Association Between Dry Eye Syndrome and Osteoarthritis Severity: A Nationwide Cross-Sectional Study (KNHANES V)

OBJECTIVE

Recently, several researchers reported an association between osteoarthritis and dry eye syndrome (DES) and suggested that they may be related to central sensitization. We investigated the association between DES, osteoarthritis pain, and radiographic severity.

DESIGN

A nationwide, cross-sectional study.

SETTING

The Fifth Korean National Health and Nutrition Examination Survey.

SUBJECTS

8,664 participants in this survey.

METHODS

Osteoarthritis-associated radiographic changes were evaluated by trained radiologists. Multivariable logistic regression was performed to examine the relationship between osteoarthritis pain, radiographic severity, and DES. The odds ratios (ORs) of DES were analyzed in accordance with the presence of osteoarthritis-associated factors.

RESULTS

Radiographic knee osteoarthritis was significantly associated with lower ORs for DES (OR = 0.80, P = 0.046, for diagnosed/self-reported DES; OR = 0.84, P = 0.034, for symptoms of DES). Knee pain or stiffness was significantly associated with higher ORs for DES (OR = 1.28, P = 0.020, for diagnosed/self-reported DES; OR = 1.29, P = 0.003, for symptoms of DES). In patients with symptomatic osteoarthritis, DES was not significantly associated with radiographic severity of osteoarthritis. In patients with nonsymptomatic radiographic osteoarthritis, DES was inversely related with radiographic severity (Ptrend = 0.012 for diagnosed/self-reported DES; Ptrend < 0.001 for symptoms of DES).

CONCLUSIONS

Radiographic osteoarthritis showed a significant association with decreased DES. Patients with less pain and severe radiographic OA were more likely to have less DES. Our results suggest that the degree of pain caused by osteoarthritis and central sensitization may be closely associated with DES.

Systemic, environmental and lifestyle risk factors for dry eye disease in a mediterranean caucasian population

OBJECTIVES

To assess systemic, environmental and lifestyle risk factors for dry eye disease (DED) in a Mediterranean Caucasian population.

METHODS

A cross-sectional study was performed on 120 Caucasian participants aged between 18 and 89 years (47.0 ± 22.8 years). Medical history, information regarding environmental conditions and lifestyle, Ocular Surface Disease Index, Dry Eye Questionnaire-5, non-Invasive (Oculus Keratograph 5 M) breakup time, tear film osmolarity and ocular surface staining parameters were assessed in a single clinical session to allow DED diagnosis based on the guidelines of the Tear Film and Ocular Surface Society Dry Eye Workshop II Diagnostic Methodology Report. A multivariate logistic regression model was constructed including those variables with a p-value less than 0.15 in the univariate analysis.

RESULTS

A prevalence of 57.7 % for DED was found. No age differences were found between those with and without DED (U = 1886.5, p = 0.243). Nevertheless, the DED group had more females (X² = 7.033, p = 0.008). The univariate logistic regression identified as potential risk factors for DED the following: female sex, sleep hours per day, menopause, anxiety, systemic rheumatologic disease, use of anxiolytics, daily medication, ocular surgery, poor diet quality, more ultra-processed food in diet, not drinking caffeine and hours of exposure to air conditioning per day. Multivariate logistic regression revealed that hours of sleep per day, menopause and use of anxiolytics were independently associated with DED (p ≤ 0.026 for all).

CONCLUSIONS

DED is associated with systemic, environmental and lifestyle risk factors. These findings are useful to identify potentially modifiable risk factors, in addition to conventional treatments for DED.

Influence of Different Antidepressants on Ocular Surface in Patients With Major Depressive Disorder

PURPOSE

Several studies have previously reported the association between dry eye and depression along with the treatment of depression. The aim of this study was to investigate the effects of different antidepressant drugs on tear parameters in patients with major depressive disorder.

METHODS

We recruited 132 patients who were using different antidepressants and 58 healthy controls. Venlafaxine, duloxetine, escitalopram, and sertraline were used by 34, 28, 36, and 34 patients, respectively. The participants filled out and completed the Beck Depression Scale. We recorded Schirmer test, tear breakup time (TBUT) and corneal staining values of the participants. The Ocular Surface Disease Index was completed by the participants. In addition, we evaluated the tear meniscus parameters by using anterior segment optical coherence tomography.

RESULTS

All conventional dry eye tests and tear meniscus parameters were significantly lesser in the depression group than in the control group (Schirmer test, 11.41 ± 6.73 mm and 22.53 ± 4.98 mm; TBUT, 5.29 ± 2.92 seconds and 13.38 ± 1.72; Corneal staining, tear meniscus area, 0.026 ± 0.012 mm2 and 0.11 ± 0.025 mm2; tear meniscus depth, 182.75 ± 78.79 μm and 257.48 ± 90.1 μm; tear meniscus height, 290.3 ± 133.63 μm and 459.78 ± 180.26 μm, in patients and controls, respectively). The tear parameters of the duloxetine group were lowest among the drug groups and Schirmer test, and TBUT of the venlafaxine group was statistically significantly different from the duloxetine group (P = 0.028 and P = 0.017, respectively). Ocular Surface Disease Index score of the depression group was significantly higher than the control group (31.12 ± 21.15 and 17.43 ± 11.75 in depression and control group, respectively.).

CONCLUSIONS

We found that the usage of selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors affects the ocular surface by a mechanism other than the anticholinergic system. Besides serotonin blockage, the noradrenaline blockade of serotonin noradrenaline reuptake inhibitors may increase the dry eye findings on the ocular surface.

Systemic Conditions Associated with Severity of Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management Study

PURPOSE

Certain systemic conditions are reported to be risk factors for dry eye disease (DED), but their associations with DED severity are not well studied. We evaluated whether systemic conditions reported to be DED risk factors are associated with severity of DED signs and symptoms.

DESIGN

Secondary analysis of data from the Dry Eye Assessment and Management Study, a large-scale multicenter randomized clinical trial of patients with moderate to severe DED.

PARTICIPANTS

Five hundred thirty-five adult patients with moderate to severe DED from 27 United States centers.

METHODS

Patients reported their medical history at baseline. They underwent ocular surface examinations and symptom evaluation using standardized protocols at baseline, 6 months, and 12 months. We analyzed the associations of systemic conditions (a systemic disease or smoking history) reported as potential DED risk factors with the severity of DED signs and symptoms using generalized linear regression models adjusted by age, gender, race, and visit.

MAIN OUTCOME MEASURES

Dry eye disease symptoms assessed using the Ocular Surface Disease Index (OSDI), 6 DED signs (tear film break-up time, anesthetized Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, tear osmolarity, and meibomian gland dysfunction), and a composite signs severity score from 0 to 1 (1 = most severe).

RESULTS

The mean age was 58 years; 81% were women. More severe DED signs were associated significantly with Sjögren syndrome (mean composite signs severity score 0.52 with disease vs. 0.43 without disease; P < 0.001), facial rosacea (0.47 vs. 0.43; P = 0.002), rheumatoid arthritis (0.47 vs. 0.42; P = 0.002), peripheral artery disease (0.50 vs. 0.43; P < 0.001), and daily smoking history (0.45 vs. 0.43; P = 0.047). Thyroid dysfunction, osteoarthritis, diabetes, irritable bowel syndrome, hypercholesterolemia, hypertension, and hypertriglyceridemia were not associated significantly with DED signs. No conditions were associated significantly with OSDI.

CONCLUSIONS

In this large, well-characterized cohort of patients with DED assessed under standardized procedures, patients with certain systemic diseases and smoking history showed more severe DED signs compared with patients without the conditions. The profile of significant DED signs varied by systemic condition, reflecting different DED causes. Understanding the systemic conditions and underlying causes that predispose some patients to severe DED can improve management.

Risk Factors Influencing the Occurrence and Severity of Symptomatic Dry Eye Syndrome: A Cross-sectional Study

Propose: We aimed to investigate the prevalence and risk factors of dry eye syndrome (DES) among a population-based cohort study.Methods: This cross-sectional study was conducted on 475 subjects (184 men and 291 women) enrolled in the Study Group for Environmental Eye Disease at July 2013. Using the ocular surface disease index (OSDI), we measured the DES severity and defined DES as OSDI score ≥13. Current symptoms of DES and possible risk factors such as body mass index, occupations, comorbidities, exercise, smoking and drinking status were assessed by multivariate logistic regression.Results: Prevalence of DES was significantly higher in women (52.6%) than in men (41.9%) (p < .001). Compared to white-collar workers, blue-collar workers and unemployed persons showed significantly higher DES prevalence and severity. Compared to those with low BMI (<23.0 kg/m²), people with extremely high BMI (≥30.0 kg/m²) had significantly higher odds ratio (OR) of having DES after fully adjusted for sex, age, hypertension, diabetes, menopausal status, hormone replacement therapy, occupation, and lifestyle factors (OR: 2.83, 95% confidence interval: 1.04-7.71).Conclusions: We found some novel factors which have been unknown to the relationship with DES through the five years observation of the cohort. The positive associations of unemployment status, blue-collar work, alcohol habit, and obesity with DES suggests a person's comprehensive condition, not individual factors, contribute significantly in developing DES. Further studies will be helpful to understand the underlying mechanisms.

Association between dry eye and traditional Chinese medicine body constitutions: A Taiwanese adults study

In the theory of traditional Chinese medicine (TCM), except for the balanced constitution, other constitutions are unbalanced and may lead to susceptibility to certain diseases. This study made the first efforts to explore the relationship between TCM constitutions and the dry eye condition.This cross-sectional study collected information from 2760 subjects aged 30 to 70 years who had participated in a questionnaire survey conducted by Taiwan Biobank (TWB) in 2012 to 2017. The questionnaire included questions on basic demographic characteristics, chronic diseases, depression, blood lipid levels, lifestyles, and drug allergies, as well as a TCM constitution scale developed by a research team of TCM constitution and syndrome at China Medical University College of Chinese Medicine.Unadjusted and stratified multiple logistic regression analyses were performed to explore the relationships between TCM constitutions and dry eye. The analysis revealed that subjects falling into the constitution category of Yang deficiency, Yin deficiency, or Phlegm stasis were more likely to develop dry eyes (crude odds ratio [OR] = 1.741, 95% confidence interval [CI] = 1.361-2.227; crude OR = 2.4821, 95% CI = 1.968-3.131; and crude OR = 2.082, 95% CI = 1.597-2.714, respectively). After adjusting for important risk factors (demographic characteristics, chronic diseases, blood lipid levels, lifestyles, depression, and drug allergies), subjects with an unbalanced constitution were 1.6 to 2.5 times more likely to develop dry eye than those with a balanced constitution.These results confirm a high correlation of TCM constitution with dry eye. Considering that the current treatment outcome is not fully satisfactory to the patients with dry eyes, integration of TCM and Western medicine may be an alternative treatment option. Individualized treatments and lifestyle recommended should be provided to patients with different TCM constitutions to alleviate dry eye symptoms.

Association of Systemic Comorbidities with Dry Eye Disease

We investigated the association between dry eye disease and systemic comorbidities, including dry eye subtype, quality of life (QOL) and health utility among patients with dry eye disease. This cross-sectional, observational study enrolled 449 patients with dry eye disease (386 females; mean age, 62.6 ± 15.7 [range, 21–90] years). Ophthalmic examination findings included tear film break-up time (TBUT), Schirmer I value and keratoconjunctival staining score. QOL and health utility were evaluated using the Dry Eye-Related Quality-of-Life Score (DEQS) and Human Utility Index Mark 3 (HUI-3), respectively. Background information, including systemic comorbidities, was obtained. Prevalence of systemic comorbidities was 48.8% (219/449). No significant difference occurred between DEQS and systemic comorbidity. However, patients with dry eye disease and systemic comorbidities (depression and insomnia) exhibited significantly worse ocular surface parameters, particularly regarding TBUT, than those without. Dry eye disease with insomnia or depression comorbidity significantly correlated with friction-related diseases (including conjunctivochalasis or lid wiper epitheliopathy). A high prevalence of several systemic comorbidities occurred in patients with dry eye disease. This study shows an association between ocular signs and systemic comorbidities, particularly depression and insomnia. Ophthalmologists should be aware of patients’ systemic comorbidities in the diagnosis and management of dry eye disease.

The Immunological Basis of Dry Eye Disease and Current Topical Treatment Options

Homeostasis of the lacrimal functional unit is needed to ensure a well-regulated ocular immune response comprising innate and adaptive phases. When the ocular immune system is excessively stimulated and/or immunoregulatory mechanisms are disrupted, the balance between innate and adaptive phases is dysregulated and chronic ocular surface inflammation can result, leading to chronic dry eye disease (DED). According to the Tear Film and Ocular Surface Society Dry Eye Workshop II definition, DED is a multifactorial disorder of the ocular surface characterized by impairment and loss of tear homeostasis (hyperosmolarity), ocular discomfort or pain, and neurosensory abnormalities. Dysregulated ocular immune responses result in ocular surface damage, which is a further contributing factor to DED pathology. Several therapeutics are available to break the vicious circle of DED and prevent chronic disease and progression, including immunosuppressive agents (steroids) and immunomodulators (cyclosporine and lifitegrast). Given the chronic inflammatory nature of DED, each of these agents is commonly used in clinical practice. In this study, we review the immunopathology of DED and the molecular and cellular actions of current topical DED therapeutics to inform clinical decision making.

Evaluation of dry eye disease in newly diagnosed anxiety and depression patients using anterior segment optical coherence tomography

Background

We aimed to evaluate dry eye diseases (DED) in patients with newly diagnosed depression and anxiety patients.

Methods

Forty newly diagnosed depression, 35 anxiety patients, and 37 controls without any history of taking psychiatric drugs (or before the beginning of psychiatric medication) and topical ophthalmic drop use, were included in the study. All depression and anxiety diagnoses were performed by an experienced psychiatrist. Beck depression and anxiety tests were used to measure disease severity. Tear film break up time (TBUT), Schirmer’s test, Oxford scores and ocular surface disease index (OSDI) were admiinistered to participants. Anterior segment optical coherence tomography was used to measure tear meniscus heights (TMH), tear meniscus depths (TMD) and tear meniscus areas (TMA).

Results

In anxiety and depression groups, Schirmer’s test (mm) (7.24 ± 6.02, 6.58 ± 4.9 and 18.79 ± 4.9 respectively, p < 0.05) and TBUT (s) (5.62 ± 3.1, 5.6 ± 3.5 and 13.37 ± 1.7 respectively, p < 0.05) were significantly lower than control group. In addition, OSDI and Oxford scores were significantly higher than controls. OSDI scores were 28.01 ± 19, 30.43 ± 18.49, 14.38 ± 8.14 respectively (p = 0.002) and Oxford scores were 1.9 ± 0.7, 2.1 ± 0.6 and 0.7 ± 0.4 respectively (p = 0.001). TMD, TMH and TMA values were significantly lower in anxiety and depression groups compared with control groups. Correlations between disease inventory scores and dry eye tests were detected.

Conclusions

This study showed a relation between DED and newly diagnosed anxiety and depression patients with no history of psychiatric drug use. The presence of correlation between dry eye tests and disease inventory scores strengthens this association. This is an important knowledge that need to be evaluated in these patients before starting psychiatric medication.

Diabetes mellitus is associated with dry eye syndrome: a meta-analysis

BACKGROUND

Dry eye is the most common eye disorder of tears and ocular surface. However, the extent to which diabetes mellitus may confer risk of dry eye remains uncertain. The aim of this study was to perform a meta-analysis that synthesizes the association between diabetes mellitus and dry eye.

METHODS

Case-control studies were selected from the Medline, Embase, Cochrane database from January 2000 to March 2018. Two reviewers screened potential studies, and eligible studies were included according to keywords and predefined criteria. We calculated the overall risk estimates by using a fixed-effect model or a random-effects model in relation to heterogeneity.

RESULTS

A total of four studies were included in our meta-analysis consisting of 2,504,794 persons. Our study showed a significant association between diabetes mellitus and the risk of dry eye syndrome (OR 1.30; 95% CI 1.08-1.57; P value = 0.006). However, the heterogeneity was observed (P value < 0.001, I² = 95.2%).

CONCLUSION

Our meta-analysis suggests that diabetes mellitus has a significant association with the risk of dry eye. However, this result is limited by heterogeneity. Further prospective and concise studies are needed to confirm the association between diabetes mellitus and dry eye.

The relationship between occupation and dry eye

INTRODUCTION

Environmental factors play an important aetiological role in dry eye. This cross-sectional study investigated the relationship between types of occupation and symptomatic dry eye.

METHODS

40,501 employed people working ≥8 h a week were included from the population-based Lifelines cohort in the Netherlands. Logistic regression was used to determine the association between symptomatic dry eye (assessed by the WHS questionnaire) and occupation (using the ISCO-08 classification system).

RESULTS

After correction for age and sex, the professionals (e.g. legal, health, and business and administration professionals) (OR = 1.14, 95%CI = 1.08-1.19, P < 0.001) and clerical support workers (OR = 1.14, 95%CI = 1.07-1.22, P < 0.001) had the highest risk of dry eye of all 10 major occupation groups. Skilled agricultural workers (OR = 0.57, 95%CI = 0.49-0.67, P < 0.001) and elementary occupations (OR = 0.77, 95%CI = 0.69-0.85, P < 0.001), such as cleaners and carers, carried the lowest risk of dry eye. After additional correction for 45 dry eye associated comorbidities, professionals and clerical support workers showed no increased risk anymore, while craft and related trades workers, e.g. building workers and metal and machinery workers, showed the highest risk of dry eye (OR = 1.12, 95%CI = 1.02-1.24, P = 0.01).

CONCLUSIONS

This study underlines the importance of asking about type of occupation in dry eye patients. Screening for symptomatic dry eye in high risk occupations such as in building workers and in indoor occupations with high screen use is relevant from an occupational health and work productivity perspective. The lower risk of dry eye in outdoor and active occupation is intriguing and justifies future studies to investigate potential protective and treatment effects.

Comorbidities and Prescribed Medications in Patients With or Without Dry Eye Disease: A Population-Based Study

PURPOSE

To assess the proportion of comorbidities in patients with dry eye disease (DED) compared with matched patients without DED in a comprehensive US population.

DESIGN

Retrospective case-control study.

METHODS

Healthcare records for insurance claims data, detailing medical services incurred by military personnel and their families and dependents in military and civilian facilities across the United States from January 1, 2003, to March 31, 2015, were obtained from the Department of Defense (DOD) Military Health System (MHS). Diagnostic and procedural codes related to DED from selected International Classification of Diseases, Ninth Revision (ICD-9) Current Procedural Terminology codes and prescriptions for cyclosporine A ophthalmic emulsion were used to identify patients with newly diagnosed and prevalent DED in the MHS database. Age, sex, and geographically matched patients without DED were also identified from healthcare claims records. Medication use and comorbidities in these patient populations were assessed and compared.

RESULTS

In both the newly diagnosed and prevalent DED samples, the most common comorbidities were hypertension, cataracts, thyroid disease, type 2 diabetes, and glaucoma. All comorbidities were significantly higher in the DED vs non-DED groups (P < .001). Medication use (including, but not limited to, ophthalmic agents and drugs to treat comorbidities) was also significantly higher in the DED than in the non-DED groups (P < .001).

CONCLUSIONS

The high proportions of patients with DED with a range of comorbidities and prescribed medications highlight the need for a multidisciplinary approach to the management of these patients.

Factors Associated with Dry Eye Symptoms in Elderly Koreans: the Fifth Korea National Health and Nutrition Examination Survey 2010-2012

Background

Dry eye disease is an aging-related ophthalmic disease that not only affects the daily activities but also causes deterioration in the quality of life. This study aimed to evaluate the factors associated with dry eye symptoms in elderly Koreans.

Methods

We investigated 4,185 subjects (men=1,787 and women=2,398) aged ≥65 years from the fifth Korea National Health and Nutrition Examination Survey 2010−2012. Data were analyzed using multiple logistic regressions to identify the relationships between dry eye symptoms and other factors.

Results

The prevalence of dry eye symptoms was 17.9%. After adjustment for confounding factors, dry eye symptoms were significantly associated with female sex (adjusted odds ratio [aOR], 1.806; 95% confidence interval [CI], 1.410−2.313), a history of cataract (aOR, 1.683; 95% CI, 1.255−2.255), suicidal ideation (aOR, 1.414; 95% CI, 1.070−1.870), hypercholesterolemia (aOR, 1.289; 95% CI, 1.025−1.621), age ≥80 years (aOR, 0.538; 95% CI, 0.337−0.859), and sleep duration ≥9 h/d (aOR, 0.524; 95% CI, 0.330−0.834).

Conclusion

Among elderly Koreans, female sex, a history of cataract, suicidal ideation, and hypercholesterolemia may be the risk factors for dry eye symptoms, whereas sleep duration ≥9 h/d can be a protective factor against dry eye symptoms.

Hospital-based analysis of eye diseases at Karitas Hospital, Southwest Sumba, 2015

Background: This study aimed to determine the profile of eye diseases at Karitas Hospital in Southwest Sumba during 2015.Methods: The cross-sectional and descriptive study was conducted by analyzing medical records of 1706 patients who presented with eye complaints at Karitas Hospital, Southwest Sumba, in 2015. Complete medical records were recovered from 1363 patients, who served as subjects for this study.Results: Thirty-six percent of subjects were elderly (>55 years old) and 9.9% were children (<18 years old). Female patients comprised 56.4% of the study population and males 43.6%. Non-infectious eye diseases dominated (89.8%; 95%CI: 88.2%–91.4%) compared to infectious diseases (8.2%; 95%CI: 6.7%–9.7%) and mixed cases (2%; 95%CI: 1.3%–2.7%). Avoidable causes of blindness, cataract (34%), and refractive error (17.3%), were mostly found among non-infectious cases, while conjunctivitis (52.7%) and keratitis (17%) were the most commonly encountered infectious diseases.Conclusion: Eye diseases at Karitas Hospital in Southwest Sumba mostly comprised non-infectious diseases. The most commonly noted non-infectious diseases were cataracts and refractive errors, while conjunctivitis and keratitis were the most commonly found infectious diseases. Due to the high amount of patients seeking eye care within Southwest Sumba, ophthalmologists and proper equipment are needed at the Karitas Hospital.

Relationship between Dry Eye Syndrome and Frequency of Coffee Consumption in Korean Adults: Korea National Health and Nutrition Examination Survey V, 2010-2012

Background

Dry eye syndrome is a common health problem in the adult population. Many risk factors including age, sex, prior eye surgery, various chronic diseases, and lifestyle factors can affect its development. We have evaluated the risk of dry eye syndrome based on the frequency of coffee consumption among Korean adult population.

Methods

A total of 9,752 adults with age 19 years and older were randomly selected between 2010 and 2012. They have all participated in the National Health and Nutrition Examination Survey V of Korea. Dry eye syndrome was being diagnosed by the physicians at some points in the participant’s lifetime. The average daily coffee intake was divided into the following: less than 1 cup, 1 to 2 cups, and 3 cups or more. Various physio-environmental factors and medical conditions were used as correction variables to assess the risk of dry eye syndrome in relation to the frequency of coffee consumption.

Results

The prevalence of dry eye syndrome decreased to 9.2%, 8.8%, and 6.3% as coffee consumption increased from less than 1 cup to 1–2 cups and more than 3 cups, respectively. However, there was no significant relationship between the frequency of coffee consumption and the risk of dry eye syndrome after adjusting various risk factors.

Conclusion

There is no relationship between the frequency of coffee consumption and risk of dry eye syndrome.

Factors associated with severe dry eye in primary Sjögren's syndrome diagnosed patients

INTRODUCTION

Primary Sjögren's syndrome (pSS) is an autoimmune disease, characterized by lymphocytic infiltration of exocrine glands and other organs, resulting in dry eye, dry mouth and extraglandular systemic findings.

OBJECTIVE

To explore the association of severe or very severe dry eye with extraocular involvement in patients diagnosed with primary Sjögren's syndrome.

METHODS

SJOGRENSER registry is a multicenter cross-sectional study of pSS patients. For the construction of our main variable, severe/very severe dry eye, we used those variables that represented a degree 3-4 of severity according to the 2007 Dry Eye Workshop classification. First, bivariate logistic regression models were used to identify the effect of each independent variable on severe/very severe dry eye. Secondly, multivariate analysis using regression model was used to establish the independent effect of patient characteristics.

RESULTS

Four hundred and thirty-seven patients were included in SJOGRENSER registry; 94% of the patients complained of dry eye and 16% developed corneal ulcer. Schirmer's test was pathological in 92% of the patients; 378 patients presented severe/very severe dry eye. Inflammatory articular involvement was significantly more frequent in patients with severe/very severe dry eye than in those without severe/very severe dry eye (82.5 vs 69.5%, p = 0,028). Inflammatory joint involvement was associated with severe/very severe dry eye in the multivariate analysis, OR 2.079 (95% CI 1.096-3.941).

CONCLUSION

Severe or very severe dry eye is associated with the presence of inflammatory joint involvement in patients with pSS. These results suggest that a directed anamnesis including systemic comorbidities, such as the presence of inflammatory joint involvement or dry mouth in patients with dry eye, would be useful to suspect a pSS.

Evaluation of Dry Eye Using Anterior Segment Optical Coherence Tomography in Patients With End-Stage Renal Disease Undergoing Hemodialysis

The aim of the present study was to evaluate dry eye parameters with conventional tests and tear meniscus with Anterior Segment Optical Coherence Tomography (AS-OCT) in patients with end-stage renal disease (ESRD). Thirty-eight ESRD patients undergoing hemodialysis, and 40 healthy individuals were enrolled. An ocular surface disease index questionnaire (OSDI) was administered. Before conventional dry eye tests, tear meniscus were evaluated using AS-OCT. After a complete ocular examination, Schirmer and break-up time (BUT) tests were performed and probable corneal staining was investigated. Schirmer test and BUT values were significantly lower in ESRD patients (P < 0.05). OSDI scores and corneal staining scores were significantly higher in ESRD patients (P < 0.05). Tear meniscus height, tear meniscus depth, and tear meniscus area, which were obtained by AS-OCT were significantly lower in patients with ESRD (P < 0.05). Tear meniscus evaluation using AS-OCT is an effective and non-invasive method to assess tear meniscus in patients with ESRD. Patients with ESRD undergoing hemodialysis should obtain regular ophthalmic examination, especially for dry eye.

Measurement of Symptoms Pre- and Post-treatment of Dry Eye Syndromes

: Valid assessment of dry eye syndrome symptoms is essential for diagnosis and for making treatment decisions and monitoring responses to treatment. Notwithstanding the desirability of being able to measure across several assessment domains to gauge the influence of symptom burden on the quality of life, the time-consuming nature of such assessments may make them unsuitable for routine clinical use. This review of symptom assessment methods examines the relative merits of visual analogue and Likert scales. Also examined are ways in which symptoms can be influenced by comorbid diseases and associated medications, and how the validity of assessing treatment efficacy could be compounded by natural progression of a dry eye syndrome apart from either favorable, neutral, or adverse responses to treatment. Follow-up assessments may also be biased by patient expectations. How validity of responses could be improved by the instructional use of a demonstration scale is described and illustrated. Personal instruction is suggested for patients anticipated to have age- or language-related difficulties but for some patients instruction could be successfully self-directed. A comparison of methods used to monitor dry eye syndrome treatment has allowed recommendations to be made for a method of using visual analogue scales which incorporates features which have been demonstrated to be advantageous in previous studies. The continuous nature of a visual analogue scale allows for smaller changes to be recorded with associated better discriminating capacity. More powerful statistical analysis of findings is possible when using visual analogue scales. Reference to previous assessment scores and exactly the same scale anchors improve the reliability of measurements of change in symptoms over time.

Visual Fatigue Induced by Viewing a Tablet Computer with a High-resolution Display

Purpose

In the present study, the visual discomfort induced by smart mobile devices was assessed in normal and healthy adults.

Methods

Fifty-nine volunteers (age, 38.16 ± 10.23 years; male : female = 19 : 40) were exposed to tablet computer screen stimuli (iPad Air, Apple Inc.) for 1 hour. Participants watched a movie or played a computer game on the tablet computer. Visual fatigue and discomfort were assessed using an asthenopia questionnaire, tear film break-up time, and total ocular wavefront aberration before and after viewing smart mobile devices.

Results

Based on the questionnaire, viewing smart mobile devices for 1 hour significantly increased mean total asthenopia score from 19.59 ± 8.58 to 22.68 ± 9.39 (p < 0.001). Specifically, the scores for five items (tired eyes, sore/aching eyes, irritated eyes, watery eyes, and hot/burning eye) were significantly increased by viewing smart mobile devices. Tear film break-up time significantly decreased from 5.09 ± 1.52 seconds to 4.63 ± 1.34 seconds (p = 0.003). However, total ocular wavefront aberration was unchanged.

Conclusions

Visual fatigue and discomfort were significantly induced by viewing smart mobile devices, even though the devices were equipped with state-of-the-art display technology.

Dry eye disease and allergic conditions: A Korean nationwide population-based study

BACKGROUND

Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface. No epidemiologic reports have yet been published about the relationship between DED and allergic rhinitis or sensitization to allergens.

OBJECTIVE

To investigate the association between DED and allergic conditions in the general adult Korean population.

METHODS

This population-based cross-sectional study included 17,542 individuals (ages ≥ 19 years) who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2010 to 2012. Data for total serum immunoglobulin E (IgE) and allergen-specific IgE levels were available for 1857 subjects. Data were analyzed by using logistic regression to determine the association of DED with allergy or allergic conditions, including allergic rhinitis, atopic dermatitis, asthma, increased total serum IgE, and sensitization to house-dust mite (Dermatophagoides farinae), dog, and cockroach allergens.

RESULTS

The prevalence of DED, allergic rhinitis, atopic dermatitis, and asthma was 10.4, 13.1, 2.2, and 3.3%, respectively. The prevalence of the increased total serum IgE level and sensitization to D. farinae, dog, and cockroach allergens was 34.6, 15.7, 1.0, and 2.8%, respectively. After adjusting for general characteristics, DED was significantly associated with allergic rhinitis (odds ratio 1.58 [95% confidence interval, 1.38-1.81]) and D. farinae sensitization (odds ratio 1.80 [95% confidence interval, 1.17-2.79]).

CONCLUSION

This study demonstrated a close association between DED and both allergic rhinitis and D. farinae sensitization in Korean adults. Further studies are warranted to establish temporal relationships between DED and allergic rhinitis.