2012 Annual Report on Dry Eye Diseases

Contact Lens Spectrum readers illustrate current trends in diagnosing and managing dry eye diseases.


2012 Annual Report on Dry Eye Diseases

Contact Lens Spectrum readers illustrate current trends in diagnosing and managing dry eye diseases.

By Amber Gaume Giannoni, OD, FAAO, & Jason J. Nichols, OD, MPH, PhD, FAAO

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and the Co-Director/Co-Founder of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.
Dr. Nichols is the Kevin McDaid Vision Source Professor at the University of Houston College of Optometry.

This is our fourth annual issue of Contact Lens Spectrum dedicated solely to dry eye diseases. It includes information on general and contact lens-related dry eye, diagnostic considerations, lens care solutions, pharmaceuticals, and cutting-edge patient management tips.

This particular report will serve as an update on current clinical practice trends regarding diagnosing and managing all types of dry eye sufferers.

Overview of Dry Eye Trends

We surveyed a sample of eyecare practitioners from the Contact Lens Spectrum readership via an online market survey from March 15th through April 25th, 2012. The survey covered a range of topics including frequency estimates of common dry eye conditions, preferred diagnostic methods for evaluating both general and contact lens-related dry eye, and prescribing trends. We obtained a response rate of 8.15 percent, with 457 usable respondents who completed the survey (either in whole or in part).

The next sections will discuss those results in detail.

Dry Eye Frequency, Severity, and Etiology (Non-Lens Wearers)

Eyecare practitioners encounter dry eye complaints on a daily basis, and the frequency of dry eye disease is sure to increase as our population ages. We asked for your impressions regarding the prevalence of dry eye in your non-contact lens wearers, and you stated that, on average, 35 percent (± 18.8) have some form of dry eye disease. This statistic is similar to those from our prior surveys and is comparable with population-based studies (Hikichi et al, 1995; Doughty et al, 1997; Schein et al, 1997; and others. Full list available at According to our survey, you believe that the majority of your non-lens-wearing dry eye patients (60 percent) experience the evaporative form of the disease, which is very similar to the numbers reported for your contact lens-wearing patients. As a reminder, according to the Dry Eye Workshop (DEWS) report (2007), evaporative dry eye occurs secondary to water loss from the ocular surface with an otherwise healthy and functioning lacrimal system, whereas aqueous deficient dry eye occurs when the lacrimal and conjunctival systems fail to adequately produce the aqueous portion of the tears (Lemp et al, 2007). Figure 1 compares your perceived major classifications of dry eye in non-lens wearers and in lens wearers.

Figure 1. Perceived major classifications of dry eye.

In terms of severity, only 12 percent of your general dry eye patients suffer from severe disease, while the greater proportion have mild (58 percent) or moderate (30 percent) dry eye. Figure 2 compares dry eye disease severity in non-contact lens wearers and in contact lens wearers.

Figure 2. Perceived dry eye disease severity.

Of interest, you report that the majority of your non-contact lens-wearing patients (58 percent) experience greater dry eye symptoms toward the end of the day, which is a complaint we also hear often from our contact lens wearers (Figure 3). Many eyecare practitioners believe that this diurnal symptom variation results from a poor lipid layer with tear film evaporation. Correspondingly, if this is the primary driving force behind these late-day complaints, it would be reasonable to expect an increase in tear film osmolarity. Yet to date, this does not appear to be the case as studies have shown that tear osmolarity is not affected by the time of day in normal patients (Gilbard et al, 1992; Khanal et al, 2011) or in dry eye sufferers (Begley et al, 2003), so there must be other contributing factors. Of further interest is an apparent increase in the number of your non-contact lens-wearing patients who tend to experience their worst symptoms in the morning. In 2010, you reported that only about 1 in 4 patients had greater morning complaints compared to 1 in 3 in this year's survey. Regardless, it is likely that these early-day complaints relate to the presence of blepharitis, as this condition is known to be associated with morning burning and stinging. It is also the major contributor to the evaporative form of dry eye disease.

Figure 3. Time of day for most severe symptoms.

In terms of your preferred method for dry eye testing in non-lens-wearing patients (Figure 4), the large majority of you favor tear breakup time (25 percent) and symptom assessment (19 percent). This appears to be a consistent trend for at least the past decade (Korb, 2000; Nichols et al, 2000). However, a greater percentage of you are also favoring lid margin assessment (vascularization, collarettes, and staining) as your preferred diagnostic test compared to prior years. It is possible that this increasing trend stems from the recently published efforts of the International Workshop of Meibomian Gland Dysfunction (MGD), which suggests a thorough lid feature evaluation for diagnosing MGD-related dry eye (Tomlinson et al, 2011). On average, 53 percent of you estimate that your non-contact lens dry eye patients have MGD. Along these same lines, the MGD Workshop also suggests that to properly determine the extent and severity of MGD, gland expression must be performed. Indeed, an impressive 76 percent of you are actively expressing these glands in at least some of your dry eye patients. Even though we don't have prior numbers to compare this to from our own market research, anecdotally it appears that more practitioners are assessing meibomian gland secretions than in the past. Figure 5 displays the number of practitioners who reported actively expressing meibomian glands in their dry eye patients.

Figure 4. Preferred method in making a diagnosis of dry eye in non-lens wearers.

Figure 5. Practitioners actively expressing meibomian glands in dry eye patients.

Managing Dry Eye in Non-Lens Wearers

Figure 6 shows the distribution of treatments that you prefer in managing dry eye disease in your non-contact lens wearers. The survey question asked for the one treatment that you use most frequently, which may have been difficult for you to choose as many practitioners employ several therapies concomitantly. The use of topical lubricants was prescribed most frequently by our readership sample, with 54 percent preferring artificial tears as first-line therapy. Overall, the popularity of artificial tears as your therapy of choice has declined by 15 percent compared to previous years, whereas the use of warm compresses and lid hygiene as your preferred treatment method increased by 7 percent. Again, this could possibly be attributed to an effect produced by recently published MGD Workshop Reports.

Figure 6. One treatment used most frequently for dry eye in non-contact lens wearers.

Other treatment options displayed in Figure 6 also show a small rise in popularity compared to 2010, including omega-3 oral supplements, topical steroid use, and topical azithromycin drops. However, use of these as leading treatments for dry eye in your practices remains low overall.

Contact Lens Dry Eye Frequency, Severity, Etiology, and Prognosis

Dryness and discomfort remain the top reasons reported for lens discontinuation (Weed et al, 1993; Vajdic et al, 1999; Pritchard et al, 1999; and others), and managing these symptoms in our contact lens-wearing patients continues to be a significant challenge. Interestingly, “40” seems to be the magic number: for every 100 contact lens patients you examine, you report that 40 have some form of dry eye, 40 are believed to have MGD, and 40 permanently discontinue lens wear each year due solely to the aforementioned symptoms.

As noted in Figure 2, and similar to that for noncontact lens wearers, 65 percent of your contact lens dry eye patients are of the mild variety. There is also agreement between these two subsets of patients in terms of diurnal variation of symptoms, with 84 percent of lens wearers reporting more severe symptoms at the end of the day. This is illustrated in Figure 3. Table 1 lists the characteristics of dry eye disease in both non-contact lens wearers and in contact lens-wearing patients.

Non Contact Lens WearersAverage Response
Dry Eye—Overall35 percent
ClassificationEvaporative60 percent
Aqueous Deficient40 percent
Dry eye patients who have MGD53 percent
Contact Lens WearersAverage Response
Contact Lens Dry Eye—Overall40 percent
ClassificationEvaporative57 percent
Aqueous Deficient43 percent
Contact lens wearers with MGD40 percent
Contact lens wearers who permanently discontinue lens wear each year due to dryness and discomfort problems.40 percent

Table 1. Characteristics of dry eye in both non-lens wearers and in contact lens wearers.

It is intriguing to note that your top three preferred diagnostic techniques for evaluating dry eye in contact lens wearers differ slightly in order from those for non-lens wearers. Figure 7 shows a preference for symptoms assessment (25 percent), corneal staining (19 percent) and tear breakup time (11 percent) for assessing contact lens wearers.

Figure 7. Preferred method in making a diagnosis of contact lens dry eye.

Managing Contact Lens-Related Dry Eye

We asked you specifically about your preferred management/treatment approaches for your patients who have contact lens-related dry eye, and the results appear in Figure 8. When asked about the one treatment you use most frequently, nearly half (47 percent) would refit their patients into a different contact lens. Twenty-four percent would refit into a lens with a more frequent replacement schedule, and 23 percent would refit into a different lens material with the same replacement schedule. This was followed closely by a recommendation of topical lubricants (22 percent). These numbers have basically remained unchanged since our initial survey in 2009.

Figure 8. One treatment used most frequently for treating contact lens dry eye.

Practitioners seem to be well aware of the problem at hand, but it appears that our preferred treatment methods are not helping to decrease the number of unhappy contact lens wearers in our practices. Altering the contact lens material or care solution may not make the difference that we expect if there happens to be an undiagnosed disease process involved, such as mild perennial allergy or underlying blepharitis. This will likely leave both patient and practitioner frustrated and may result in the discontinuation of lens wear. Lens cessation can have a substantial economic impact on a practice, and it may be more costly than you might initially think. It has been estimated that a single patient terminating contact lens wear can reduce the lifetime income of a practice by more than $24,000 (Rumpakis, 2010). Multiply this by the average number of total lens dropouts per year and it quickly becomes a staggering figure.

It is noteworthy to mention that although you feel a large number of your dry eye patients have MGD (both in your general dry eye patient population as well as in your contact lens wearers), few of you recommend lipid-based artificial tears as your primary treatment method (Figures 6 and 8). Only 1 percent of you recommend this option for contact lens wearers and 10 percent recommend them for non-wearers. While some may be hesitant to prescribe an oil-based lubricant for use with contact lenses, this doesn't explain the low recommendation rate for non-wearers. We didn't ask about warm compresses and lid hygiene as a primary treatment option for your contact lens wearers, which would be important to include in next year's survey.

Although respondents seemed to agree that re-fitting a patient into a new lens was the preferred treatment for symptomatic wearers, there appears to be limited accord regarding which lens material is optimal. The majority (66 percent) were of the opinion that a daily disposable modality is optimum, with 36 percent choosing daily disposable hydrogel lenses and 30 percent preferring daily disposable silicone hydrogel lenses. Twenty-two percent believe that planned replacement silicone hydrogel lenses are the most favorable lens type to solve dryness and comfort issues. As in our previous research, GP contact lenses (including corneal, scleral, and orthokeratology) were recommended by very few for managing symptomatic contact lens wear (Figure 9).

Figure 9. General contact lens category most efficacious at reducing dryness/discomfort.

Lastly, 15 percent of practitioners reported that changing care solution was their treatment of choice in managing contact lens-related dry eye. The majority of you felt that PHMB (Biguanides) preservative is most associated with discomfort (34 percent), followed by Polyquaternium/PHMB and Polyquaternium/Aldox (11 percent each), hydrogen peroxide-based care solutions (9 percent) and Polyquaternium/Alexidine (5 percent) (Figure 10). It is intriguing that 30 percent of practitioners felt that there is absolutely no difference among care solutions in this regard (that is, they are all equally likely to be associated with discomfort). Some research has corroborated this point (Ramamoorthy et al, 2008).

Figure 10. One care solution preservative most associated with discomfort.

Concluding Thoughts

Dry eye continues to be among the most common complaints that we encounter in clinical practice, and the frequency of dry eye diseases will very likely increase alongside our aging, multi-medicated population. Successful management continues to be challenging as the conditions themselves are multifactorial in origin and patients desire curative treatments, not simply palliative/temporary relief. Although our treatment methods appear to have been relatively stagnant over the past few years, changes are sure to occur in the near future as industry and academia continue to develop advanced diagnostic techniques and products to help us manage these conditions more effectively. CLS

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