2014 Report on Dry Eye Diseases

An update on practitioner trends in diagnosing and managing dry eye in both contact lens and non-lens wearers.


2014 Report on Dry Eye Diseases

An update on practitioner trends in diagnosing and managing dry eye in both contact lens and non-lens wearers.

By Anna Ablamowicz, OD, & Jason J. Nichols, OD, MPH, PhD, FAAO

Diagnosing and managing dry eye diseases can be challenging at times, but vision science research continually pushes forward innovations in diagnostic tools and an evolving plethora of topical eye drops and treatments.

Our biennial dry eye report provides new information on dry eye in both contact lens and non-lens wearers based not only on current research, but also on recommendations from eyecare professionals in practice. This year’s report includes an update on diagnostic and management trends based on a survey completed by our readers, with some exciting new statistics and comparisons from previous years.

Overview of Dry Eye Trends

This year’s survey for the dry eye report was conducted online from April 30 through May 12, 2014 and was filled out either completely or partially by 696 Contact Lens Spectrum subscribers who are eyecare providers practicing in the United States. The survey questions covered frequency estimates of dry eye disease in both non-lens and contact lens wearers as well as diagnostic and management techniques most commonly utilized in practice.

The following sections will discuss the results of the survey in detail, with comparisons to results from previous years.

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

Most, if not all, of us who see patients on a daily basis can hardly recall a day going by without at least one person having a complaint of ocular burning, stinging, and/or itching—all hallmark symptoms of dry eye disease. Staying fairly consistent with your frequency estimates from 2009 through 2012, this year’s participants report that, on average, about 33% of non-contact lens wearers have some form of dry eye. You also continue to report that a majority of these dry eye patients have evaporative dry eye (59%) versus aqueous-deficient dry eye (41%) (Figure 1). Keep in mind that the Dry Eye Workshop (DEWS) report (2007) classifies aqueous-deficient dry eye as decreased lacrimal secretion resulting in lower tear volume, whereas normal lacrimal gland secretion with increased water loss from the ocular surface is key in evaporative dry eye.

Figure 1. Perceived major classifications of dry eye.

When making any diagnosis of dry eye, it is essential to diagnose not only the type of dry eye, bearing in mind that a patient may have a mixed form of both main types, but also the severity of the disease. Before making a dry eye diagnosis, it is imperative to examine the meibomian glands, which retard evaporation of the tears by secreting the lipid layer into the tear film, to determine whether there is dysfunction in lipid secretion. The predominant method for making a diagnosis of dry eye in non-lens wearers continues to be the tear breakup test (TBUT) at 26% (Figure 2), which remains unchanged from past surveys.

Figure 2. Preferred method for diagnosing dry eye in non-lens wearers.

Secondary to the TBUT, 21% of you prefer using symptom assessment in making a diagnosis of dry eye in non-lens wearers, and indeed, more than half of our respondents (71%) state that symptoms are very important in making the diagnosis (Figure 3). It seems common that most clinicians would not make a diagnosis of dry eye unless a patient had some complaint to go along with any diagnostic signs of disease seen upon examination.

Figure 3. Importance of symptom assessment in diagnosing dry eye.

Even though only 8% of you prefer to assess the meibomian glands and only 5% prefer using expression of the meibomian glands in making a diagnosis, once the diagnosis of dry eye is made, half of our respondents (51%) actively express meibomian glands in at least some of their dry eye patients (Figure 4). Despite the wave of proprietary meibomian gland expressors, more than half of you are using your fingertip and/or a cotton-tipped swab for expression. Although these techniques are used most commonly, a standardized device that delivers a known amount of pressure to a set area may provide you with a more accurate assessment of the meibum expression. It is recommended to maintain expression for at least 10 to 15 seconds for best results (Korb and Blackie, 2008).

Figure 4. Practitioners actively expressing meibomian glands in non-lens wearers who have dry eye.

After diagnosis of dry eye, assessment of severity is useful when determining appropriate treatment plans and for monitoring progression. Although guides for grading dry eye severity exist, it is likely that there are inconsistencies among practitioners in grading severity. However, you report that more than half (57%) of all non-lens wearing patients have a mild form of the disease, whereas only 12% are severe (Figure 5), remaining at similar levels from previous reports.

Figure 5. Perceived dry eye disease severity.

Managing Dry Eye in Non-Lens Wearers

Because the etiology behind aqueous-deficient and evaporative dry eye differs, it is reasonable that different treatment strategies may be employed for each type. When asked what one treatment method you use most frequently to treat aqueous-deficient dry eye in non-contact lens wearers, 47% of you responded with artificial tears and 28% responded with Restasis (topical cyclosporine drops, Allergan) (Figure 6). For treating evaporative dry eye, it may come as no surprise that a tie occurred between use of artificial tears and warm compresses/lid hygiene at 26% each. Of note, the next preferred treatment method of evaporative dry eye was a lipid-based tear supplement at 21%.

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

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

Wearing contact lenses may exacerbate existing dry eye in some patients to the point that the disease becomes symptomatic, leading to what is known as contact lens dry eye. Often, adverse symptoms seemingly due to dry eye while wearing contact lenses can mimic what has recently been defined as contact lens discomfort, set forth in the Tear Film and Ocular Surface Society (TFOS) Contact Lens Discomfort Workshop report (Nichols et al, 2013). The distinction is that if removal of the contact lens alleviates the symptoms of dryness, then the symptoms are likely due to contact lens discomfort; the symptoms associated with a pre-existing dry eye condition persist in patients who have contact lens dry eye even after lens removal.

The frequency of dry eye among contact lens wearers is slightly higher (38%) than among non-lens wearers (33%) per your responses in 2014. This is a slight decrease from 2012, when it was 40%. You continue to report that on average, 57% of your contact lens dry eye patients have evaporative dry eye (Figure 1), with four in 10 (41%) having meibomian gland disease, both of which are unchanged from 2012.

A marked difference in this year’s report is that the average percentage of patients who discontinue contact lens wear permanently each year due to dryness and discomfort has declined significantly from 40% in 2012 to only 14% this year (Table 1). Although the reasons for this are unclear, it may be a direct result of the newer contact lens materials that have arrived on the market in the past two years and/or a greater shift toward prescribing daily disposable contact lenses.

Table 1. Characteristics of dry eye in both non-lens wearers and in contact lens wearers.
Non-Contact Lens Wearers Average Response
Dry Eye—Overall 33%
Classification Evaporative 59%
Aqueous deficient 41%
Dry eye patients who have MGD 53%
Contact Lens Wearers Average Response
Contact Lens Dry Eye—Overall 38%
Classification Evaporative 57%
Aqueous deficient 43%
Contact lens wearers who have MGD 41%
Contact lens wearers who permanently discontinue lens wear each year due to dryness and discomfort problems 14%

Virtually unchanged from 2012, you reported that nearly two-thirds (65%) of your contact lens dry eye patients have a mild form of the disease, whereas only 9% are severe (Figure 5). Also unchanged, you continue to report that the end of the day is, by far, when contact lens dry eye patients report that their symptoms are most severe (81%). Compare this to 64% of non-lens wearing dry eye patients who report end-of-day dryness to be most severe (Figure 7).

Figure 7. Time of day for most severe symptoms.

When diagnosing dry eye in non-lens wearers, we saw that TBUT was the preferred method. However, in contact lens-wearing patients, 28% of you report that your preferred method is symptom assessment, with the second most preferred at 20% reporting corneal staining and 19% reporting TBUT (Figure 8). This is similar to what we saw in 2012, indicating that symptoms and corneal staining play a larger role than TBUT does in your diagnosis of dry eye in patients who wear contact lenses. In fact, more than three-quarters (77%) of our respondents said that symptom assessment is very important when diagnosing dry eye in contact lens wearers (versus 71% in non-lens wearers) (Figure 3), and 87% of you prefer to ask questions yourself rather than using a specific questionnaire such as the Ocular Surface Disease Index (OSDI) questionnaire or the Contact Lens Dry Eye Questionnaire (CLDEQ).

Figure 8. Preferred method in making a diagnosis of contact lens dry eye.

Managing Contact Lens-Related Dry Eye

As mentioned previously, to have the greatest chance for success in treating contact lens dry eye, it is imperative to conduct a thorough ophthalmic examination to distinguish between contact lens discomfort and contact lens dry eye. Understanding the etiology will allow you to choose an appropriate treatment plan.

This year, when asked what one treatment you use most frequently for treating dry eye in contact lens wearers, refitting into a lens with a more frequent replacement schedule was the most popular at 38% (Figure 9). Previously, no single treatment has been so preferred, although this treatment was also ranked first in 2012 at 24% (21% used rewetting drops, and 23% refit into a different contact lens material in 2012). This indicates that more of us are recommending lenses that have shorter replacement schedules to improve lens comfort.

Figure 9. One treatment used most frequently for treating contact lens dry eye.

Indeed, there seems to be a trend in the contact lens manufacturing industry of developing daily disposable contact lens materials with newer and more advanced material chemistries, designs, and optics to help meet every patient need. We also see this in your responses to the general category of lenses that you report are most efficacious at reducing dryness, with more than four in 10 of you (45%) choosing daily disposable lenses (silicone hydrogel) (Figure 10). This percentage is up from 30% in 2012. The second tier category is also daily disposable lenses, but non-silicone hydrogel at 36%.

Figure 10. General lens category most efficacious at reducing dryness/discomfort.

Overall, it again seems as though there is a trend for prescribing daily disposable lenses to reduce lens dryness issues experienced by patients. Only 10% of you report that you recommend a change in care solution as your preferred treatment for contact lens-wearing dry eye patients. Indeed, there is no real consensus as to which care solution preservative is most associated with discomfort, with 32% reporting PHMB and 33% reporting that they all have the same impact (PHMB biguanides, polyquaternium/PHMB, aldox, hydrogen peroxide, and alexidine).

Concluding Thoughts

Dry eye continues to be a prevalent disease among patients seen by eyecare professionals. In contact lens wearers, we must always be vigilant in distinguishing between contact lens discomfort versus contact lens dry eye to initiate successful treatment plans.

Although a majority of you rely on symptoms for diagnosis of dry eye, newer research indicates that only 57% of patients who have dry eye disease report symptoms related to dry eye (Sullivan et al, 2014). As such, it is unlikely that eyecare professionals perform appropriate dry eye diagnostic testing without a patient complaint and thus may be missing the opportunity to identify patients who have a mild form of the disease and can benefit from initiating preventive treatment.

While only 16% of you report using a specific questionnaire to diagnose dry eye in non-lens wearers (13% in lens wearers), it could be advantageous to implement a specific questionnaire such as the OSDI or CLDEQ to not only aid your diagnosis of dry eye, but also for monitoring treatment effectiveness.

Advancements in contact lens materials and expanding options in daily disposable lens types should allow us to continue prescribing contact lenses that permit comfortable wear even in our patients who are predisposed to dry eye disease. It is exciting to see such a large decline in the number of patients discontinuing contact lens wear due to dryness. Hopefully this trend will continue with future advancements and innovations. CLS

For references, please visit and click on document #224.

Dr. Ablamowicz is a clinical assistant professor at the University of Alabama at Birmingham School of Optometry and is pursuing a PhD in Vision Science with a focus on biochemical properties of the tear film and dry eye disease.

Dr. Nichols is the Kevin McDaid Vision Source Professor at the University of Houston College of Optometry as well as editor-in-chief of Contact Lens Spectrum and editor of the weekly email newsletter Contact Lenses Today. He has received research funding or lecture honoraria from Vistakon, Alcon, and Allergan.