Age Is a Determining Factor of Dry Eye-Related Signs and Symptoms

Presbyopia, Dry Eye, and Retinal Thickness in the Middle-Aged Population: Focusing on Sex Differences

Purpose

Risk factors for presbyopia have not been fully determined although previous studies suggested presbyopia was associate with age, dry eye, and retinal ganglion cell complex thickness (GCC). We accessed these signs and common ocular symptoms in the middle-aged population focusing on sex differences when women have drastic hormonal change.

Methods

This cohort study consecutively enrolled 2743 patients aged 36-45 years (n=1000), 46-55 years (n=1000), and 56-65 years (n=743). All underwent ocular surface tests and had near add power and GCC measured. Common ocular symptoms were asked using questionnaire.

Results

Among female participants, visual symptoms (eye strain and photophobia) were more prevalent in the age group 46-55, whereas non-visual symptoms (dryness, irritation, and pain) were not. We identified symptomatic presbyopia (near add power ≥ 1.5D) in 14.4%, 73.8%, and 97.8%, positive corneal staining in 29.1%, 23.8%, and 23.9%, and a mean GCC of 98.2 μm, 105.3 μm, and 89.6 μm in the age groups 36-45, 46-55, and 56-65, respectively. Mean tear break-up time were 3.3, 3.5, and 3.3 seconds, respectively. Results indicated a large progression of presbyopia (P<0.01) from the period of 36-45 years onward and significantly increased GCC (P<0.01) in women of age group 46-55. No notable tendency was observed in symptoms and GCC for male participants.

Conclusion

Visual symptoms in women were worse between 46 and 55 years than before or after these ages. The increase of symptomatic presbyopia and GCC may be contributing to visual symptoms in addition to menopausal transition symptoms in this age group.

Obesity, body fat distribution and eye diseases

BACKGROUND

The prevalence of obesity, a chronic disease, is increasing, and obesity is now considered a global epidemic. Eye diseases are also increasing worldwide and have serious repercussions on quality of life as well as increasingly high costs for the community. The relationships between obesity and ocular pathologies are not yet well clarified and are not pathologically homogeneous: they seem to be somehow linked to excess body fat, especially to the distribution of adipose tissue and its ectopic deposits.

PURPOSE

Our objective was to examine the associations between obesity and anthropometric indices, including body mass index (BMI), waist circumference (WC), and the waist/hip ratio (WHR), and the risk of most widespread eye diseases, with particular attention given to the most significant metabolic mechanisms.

METHODS

This article provides a narrative overview of the effect of obesity and anthropometric measurements of body fat on prevalent eye diseases. We used the MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library databases from 1984 to 2024. In addition, we hand-searched references from the retrieved articles and explored a number of related websites. A total of 153 publications were considered.

RESULTS

There is significant evidence that obesity is associated with several eye diseases. Waist circumference (WC) and the waist/hip ratio (WHR) have been observed to have stronger positive associations with eye diseases than BMI.

CONCLUSIONS

Obesity must be considered a significant risk factor for eye diseases; hence, a multidisciplinary and multidimensional approach to treating obesity, which also affects ocular health, is important. In the prevention and treatment of eye diseases related to obesity, lifestyle factors, especially diet and physical activity, as well as weight changes, both weight loss and weight gain, should not be overlooked.

LEVEL OF EVIDENCE

Level V narrative review.

Sex Differences and Discordance Between Symptoms and Signs of Dry Eye Disease

PURPOSE

To examine the initial presenting symptoms in relation to sex and identify predictors of discordance between symptoms and signs of dry eye disease (DED) in Taiwan.

DESIGN

Retrospective cross-sectional study.

METHODS

This clinic-based cohort from a tertiary referral center in Taiwan included 1229 patients diagnosed with DED at Keelung Chang Gung Memorial Hospital in Taiwan between August 1, 2011, and July 31, 2018. Initial presenting symptoms were cross-sectionally and retrospectively collected. The composite score, indicating the discordance between symptoms and signs, was derived from the difference between the DED symptom severity score and the DED sign severity score.

RESULTS

Of 1229 patients, 975 (79.3%) were female, with a mean age of 56.7 ± 14.9 years. Initial presenting symptoms didn't show significant sex differences (all P > .05). In multivariate analysis, predictors of higher symptom severity score than sign severity score included being female (P = .011) and having a surgical history of cataract (P = .037), pterygium, or conjunctivochalasis (P = .014). Conversely, older age (P < .001) and artificial tear use (P < .001) were significant predictors of a lower symptom severity score than sign severity score.

CONCLUSIONS

Strong predictors of incongruity between DED symptoms and signs include age, gender, surgical history for cataract, pterygium or conjunctivochalasis, and artificial tear use. Ophthalmologists should prioritize symptoms for female patients and postsurgery cases. In addition, the absence of symptoms should not dismiss DED possibility in older adult patients and those using artificial tears. Notably, early recognition and enhancement of postoperative care can improve patient satisfaction and quality of life.

Association of eye strain with dry eye and retinal thickness

PURPOSE

The purpose of this cohort study was to investigate the association between the prevalence of abnormal ocular examination results and the common visual symptoms of eye strain, blurred vision and photophobia.

METHODS

Consecutive first-visit outpatients with best-corrected visual acuity better than 20/30 in both eyes were enrolled and those with a history of intra-ocular lens implantation and glaucoma were excluded. Dry eye-related examinations and retinal thickness measurement were conducted. The odds ratio (OR) was calculated with logistic regression analyses of ocular data in relation to the presence of visual symptoms.

RESULTS

A total of 6078 patients (3920 women, mean age 49.0 ± 20.4 years) were analyzed. The prevalence of each symptom was 31.8% for eye strain, 22.5% for blurred vision and 16.0% for photophobia. A significant risk factor for eye strain was short tear break-up time (TBUT) (OR 1.88), superficial punctate keratitis (SPK) (OR 1.44), and thickness of ganglion cell complex (GCC) (OR 1.30). Risk factors for blurred vision were short TBUT (OR 1.85), SPK (OR 1.24) and GCC (OR 0.59). Risk factors for photophobia were short TBUT (OR 1.77) and SPK (OR 1.32). Schirmer test value, peripapillary nerve fiber layer thickness and full macular thickness were not associated with the tested symptoms.

CONCLUSION

The current study successfully identified female gender, short TBUT, and SPK as significant risk factors for eye strain, blurred vision, and photophobia with considerable ORs.

Klotho Null Mutation Indirectly Leads to Age-Related Lacrimal Gland Degeneration in Mutant Mice

The Klotho null mutation is known to lead to accelerated aging in many organs, but its effects on tear secretion and lacrimal gland (LG) senescence have not been addressed. This study investigated whether the Klotho null mutation would lead to a dry eye status and the outcome of LG without Klotho function. The Klotho (-/-) mutant mice showed reduced LG size and tear volume on the 8th week, as compared to their littermates (+/+, +/-). Hematoxylin-Eosin and Masson's trichrome staining were performed to determine morphological changes and collagen deposition. Traits of LG aging, including acinar atrophy, thickened capsules, and more collagen depositions, were observed. Immunohistochemical detections for Klotho, α-SMA, MDA, 8-OHdG, vasoactive intestinal polypeptide (VIP), tyrosine hydroxylase (TH), MMP-2, MMP-9, and FGF-23 were performed and compared among the three genotypes (+/+, +/-, -/-) at 6 and 8 weeks of age for mechanism analyses. Unexpectedly, the Klotho protein was not detected in the LG of all the three genotypes, indicating indirect effects from the Klotho null mutation. Further analyses showed abundant MDA and 8-OHdG detected in the Klotho (-/-) LG on the 8th week, indicating elevated oxidative stress. In addition, both sympathetic and parasympathetic neural transducing activities, as represented by TH and VIP expression, respectively, and α-SMA were increased in LGs with Klotho mutations. Furthermore, MMP-2 and MMP-9 expression were elevated, with FGF-23 expression being decreased on the 8th week in the Klotho (-/-) LG. In conclusion, characteristics of age-related LG degeneration were found in the Klotho null mutant mice. These traits support the use of Klotho mutant mice as a model of age-related dry eye disease.

THE EFFECT OF PALPEBRAL FISSURE HEIGHT IN PRIMARY GAZE POSITION ON TEAR FILM STABILITY

This study aimed to investigate the effect of palpebral fissure height in primary gaze position in healthy individuals on tear film stability. In this cross-sectional study, 120 subjects (60 male and female each) were enrolled and divided according to age into two groups, i.e., group 1 (aged 18-50 years) and group 2 (aged 51 and older). Palpebral fissure height on both eyes was measured in primary gaze position with a clear plastic ruler held in a central vertical position between the upper and lower lid margin, and the standard tear break-up time (TBUT) test was performed to evaluate tear film stability. Palpebral fissure height was significantly higher in younger than older subjects in all measurements on both eyes (p<0.001), and TBUT was shorter in older than in younger subjects. In all subjects included in the study, palpebral fissure height was not related to TBUT (p=0.589). However, analyzing the two age groups separately, a significant negative correlation was found between the palpebral fissure height and TBUT in both groups of younger (p<0.001) and older (p=0.009) subjects. In conclusion, an enlarged exposed ocular surface due to higher palpebral fissure height in healthy individual's primary gaze position negatively affects tear film stability expressed by TBUT.

Simultaneous real-time analysis of tear film optical quality dynamics and functional visual acuity in dry eye disease

BACKGROUND

To assess the effect of tear film instability in dry eye disease (DED) by measuring visual performance and tear film optical quality in a simultaneous real-time analysis system.

METHODS

Thirty-seven DED participants and 20 normal controls were recruited. A simultaneous real-time analysis system was developed by adding a functional visual acuity (FVA) channel to a double-pass system. Repeated measurements of FVA and objective scatter index (OSI) were performed simultaneously with this system under blink suppression condition for 20 s. Patient-reported symptoms was evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. Mean FVA, mean OSI, and visual acuity break-up time were defined. The OSI maintenance ratio was calculated as an evaluation index to assess the difference between dynamic OSI changes and baseline OSI. The visual maintenance ratio was also calculated in the same way.

RESULTS

Moderate correlations were noted between mean OSI and FVA-related parameters (mean FVA, visual maintenance ratio, visual acuity break-up time: 0.53, - 0.56, - 0.53, respectively, P < 0.01 for all). Moderate to high correlations were noted between OSI maintenance ratio and FVA-related parameters (mean FVA, visual maintenance ratio, visual acuity break-up time: - 0.62, 0.71, 0.64, respectively, all P < 0.01). The metrics derived from the simultaneous real-time analysis system were moderately correlated with the patient-reported symptoms and the visual acuity break-up time possessed the highest correlation coefficients with OSDI total, ocular symptoms, and vision-related function (- 0.64, - 0.63, - 0.62, respectively, P < 0.01). The OSI-maintenance ratio alone appeared to exhibit the best performance of the metrics for the detection of DED with sensitivity of 95.0% and specificity of 83.8% and the combinations of FVA parameters and OSI parameters were valid and can further improve the discriminating abilities.

CONCLUSIONS

OSI-related metrics were found to be potential indicators for assessing and diagnosing DED which correlated with both subjective visual performance and patient-reported symptoms; the FVA-related metrics were quantifiable indicators for evaluating visual acuity decline in DED.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2100051650. Registered 29 September 2021, https://www.chictr.org.cn/showproj.aspx?proj=134612.

The ocular symptoms and signs during the COVID-19 pandemic

PURPOSE

The aim of this cohort study was to describe the change in ocular surface signs and symptoms before and during the COVID-19 pandemic, and to associate changes with potential pandemic-related events.

METHODS

First-visit patients from 2019 to 2021 were examined for corneal staining, lacrimal function and refraction. We assessed the presence of seven common ocular symptoms. Patients with glaucoma and macular disease were excluded. Dry eye (DE) was diagnosed according to the criteria of the Asia Dry Eye Society.

RESULTS

The mean age of 3,907 participants was 59.6±18.6y and 63.8% were female. Mean age and the prevalence of diagnosed DE and shortened tear break-up time decreased from 2019 to 2021. The prevalence of eye fatigue, blurring and photophobia decreased in 2020.

CONCLUSIONS

The prevalence of diagnosed DE did not increase among first-visit patients during the pandemic compared with 2019, despite many survey results suggesting that DE may have worsened due to frequent masking, increased screen time, mental stress, and depression under quarantine and social infection control. It might be considered however, that many elderly DE patients might have refrained from consulting an ophthalmologist and possibly delayed treatment of DE during the pandemic.

Utilizing Baidu Index to Investigate Seasonality, Spatial Distribution and Public Attention of Dry Eye Diseases in Chinese Mainland

Purpose

To explore the characteristics of spatial-temporal prevalence and public attention of dry eye diseases (DED) through Baidu Index (BI) based on infodemiology method.

Methods

The data about BI of DED were collected from Baidu search engine using "Dry eye diseases" as keyword. The spatial and temporal distribution of DED were analyzed through timeseries data decomposition as well as spatial autocorrelation and hotspot detection of BI about DED. The most popular related words and demographic characteristics were recorded to determine the public attention of DED.

Results

The trends of BI about DED in Chinese mainland had gradually increased over time with a rapid increase from 2012 to 2014 and in 2018. The results of timeseries decomposition indicated that there was seasonality in the distribution of BI about DED with the peak in winter, especially in northern regions. The geographic distribution demonstrated the search activities of DED was highest in the east of Chinese mainland while lowest in the west. The vast majority of people searching for DED were teenagers (20-29 years), with a predominance of females. Glaucoma, keratitis and conjunctivitis were the diseases most often confused with DED, and the artificial tears were the most common treatment for DED in Chinese mainland according to the BI about DED.

Conclusions

The analysis revealed the seasonality, geographic hotspots and public concern of DED through BI in Chinese mainland, which provided new insights into the epidemiology of DED.

Vision through Healthy Aging Eyes

As life expectancy grows, so too will the number of people adversely affected by age. Although it is acknowledged that many conditions and diseases are associated with age, this mini-review will present a current update of the various visual changes that generally occur in healthy individuals disregarding the possible effects of illness. These alterations influence how the world is perceived and in turn can affect efficiency or the ability to perform ordinary daily tasks such as driving or reading. The most common physical developments include a decreased pupil size and retinal luminance as well as changes both in intercellular and intracellular connections within the retina along the pathway to the visual cortex and within the visual cortex. The quantity and the physical location of retinal cells including photoreceptors, ganglion and bipolar retinal cells are modified. The clarity of intraocular organs, such as the intraocular lens, decreases. These all result in common visual manifestations that include reduced visual acuity, dry eyes, motility changes, a contraction of the visual field, presbyopia, reduced contrast sensitivity, slow dark adaptation, recovery from glare, variation in color vision and a decreased visual processing speed. Highlighting these prevalent issues as well as current and possible future innovations will assist providers to formulate treatments and thereby conserve maximum independence and mobility in the modern mature population.

Editorial of Special Issue "Differential Diagnosis for Dry Eye"

This editorial aims to summarize the scientific papers that contributed to the Special Issue "Differential Diagnosis for Dry Eye" [...].

Sleep and subjective happiness between the ages 40 and 59 in relation to presbyopia and dry eye

Purpose

The aim of this study was to explore the status of quality of life between the ages 40–59 in relation to presbyopia and dry eye.

Methods

Near add power and preferred contact lens power were examined in 219 participants at three clinics. 2000 participants completed a web-based survey on presbyopic symptoms, symptomatic dry eye, sleep quality, and subjective happiness.

Results

Mean preferred corrected visual acuity was less than 20/20 in women (vs men, P<0.01) who were more often prescribed under-corrected contact lenses, whereas men preferred full correction. According to the annual progression rate of near add power in men (0.1468D/year), the estimated difference in presbyopia progression between men and women was 0.75 years in the right eye, and 1.69 years in the left eye, implying men might suffer presbyopia earlier than women due to higher myopic power of daily use contact lenses. The web-based survey revealed that men reported lower subjective happiness than women (P<0.001) and earlier onset of presbyopic symptoms by 1.1–1.7 years (P<0.05). Men received their first reading glasses 0.8 years earlier than women (P = 0.066). Multiple regression analysis demonstrated that awareness of presbyopic symptoms, visual burden, and dry eyes were significantly correlated with poor sleep quality and subjective happiness.

Conclusion

Presbyopia and dry eye were significantly associated with sleep quality and subjective happiness in middle-adulthood.

The ocular surface immune system through the eyes of aging

Since the last century, advances in healthcare, housing, and education have led to an increase in life expectancy. Longevity is accompanied by a higher prevalence of age-related diseases, such as cancer, autoimmunity, diabetes, and infection, and part of this increase in disease incidence relates to the significant changes that aging brings about in the immune system. The eye is not spared by aging either, presenting with age-related disorders of its own, and interestingly, many of these diseases have immune pathophysiology. Being delicate organs that must be exposed to the environment in order to capture light, the eyes are endowed with a mucosal environment that protects them, the so-called ocular surface. As in other mucosal sites, immune responses at the ocular surface need to be swift and potent to eliminate threats but are at the same time tightly controlled to prevent excessive inflammation and bystander damage. This review will detail how aging affects the mucosal immune response of the ocular surface as a whole and how this process relates to the higher incidence of ocular surface disease in the elderly.

Does Orthokeratology Wearing Affect the Tear Quality of Children?

Orthokeratology is currently known as one of the most effective methods of myopia control in the process of rapid deterioration of the global myopia prevalence. As orthokeratology is widely used, it is necessary to evaluate its complications reasonably and accurately. Eye surface problems in children, such as dry eyes, have received increasing attention. At present, there is no conclusive evidence on how orthokeratology affects the ocular surface, especially the tears. To our knowledge, this is the first study to explore the relationship between orthokeratology lenses and tears through meta-analysis. However, it is still challenging to get a convincing conclusion and a higher level of evidence in this meta-analysis. Reasons for this include limitation of study design, lack of clarity on important confounding factors, lack of appropriate statistical tools, and other biases. This paper will analyze the dilemma existing in the current research from different perspectives to provide meaningful information for future studies in this field.

Strip Meniscometry Correlates With Ocular Surface Tests and Symptoms

Purpose

The aim of this study was to investigate the association of dry eye disease (DED)-related signs and symptoms with two tear function tests.

Methods

This was a clinic-based, cross-sectional study with recruitment of consecutive participants. Schirmer test (ST), tear strip meniscometry (SM), and fluorescein tear breakup time were measured and corneal staining score was examined in outpatients at three clinics. Seven subjective symptoms were assessed by interview, including dryness, irritation, pain, lacrimation, fatigue, blurring, and photophobia. Statistical analyses included regression analysis and comparison tests.

Results

The mean age of the 210 participants was 61.2 ± 15.2 years (range, 12-91 years), with 135 women (64.3%) in the cohort. The mean ST value was 12.9 ± 9.3 (0-35) mm, and SM was 2.5 ± 1.6 (0-10) mm, with no difference between women and men. SM values were lower in the presence of irritation (P = 0.046) and photophobia (P = 0.011). Regression analysis revealed ST and SM values were strongly correlated (β = 0.255, P < 0.001). SM was significantly correlated with breakup time (β = 0.149, P = 0.032), whereas there was no correlation between ST and DED-related signs and symptoms.

Conclusions

SM was correlated with DED-related symptoms and breakup time, whereas ST was not. A low SM value could be an alternative clinical parameter to determine tear film-oriented therapy.

Translational Relevance

Tear strip meniscometry could be a useful tear function examination on a routine clinical basis since it is a 5-second noninvasive procedure and associated with subjective symptoms and the value of the conventional Schirmer test.