DRY EYE REPORT
2016 Report on Dry Eye Diseases
The readers of Contact Lens Spectrum report their trends for dry eye diagnosis and management.
By Anna F. Ablamowicz, OD, FAAO, & Jason J. Nichols, OD, MPH, PhD, FAAO
Despite recent innovations in dry eye diagnostics, the multifactorial and pervasive nature of dry eye disease continues to affect millions of people. For contact lens wearers, while newer, more biocompatible contact lenses are being developed to combat this, discomfort is still the main reason for contact lens discontinuation (International Dry Eye WorkShop [DEWS] Report, 2007). This article presents the survey results of our biennial dry eye report, which confirm this trend and will also highlight the value placed on symptoms in making a dry eye diagnosis. Read on to learn about the current diagnostic and treatment practice trends of your colleagues, with an update on current etiologies behind dry eye disease.
Overview of Dry Eye Trends
This year’s survey for the dry eye report was conducted online from March 23 through the end of May 2016 and was completed by 203 eyecare practitioners. The majority of respondents (more than 95%) currently practice in the United States. The questions contained within the survey cover estimates of the frequency of dry eye in both non-lens and contact lens wearers as well as commonly used diagnostic tools and treatments implemented in practice. The next sections will examine the results of this year’s survey in detail and will provide comparisons to results from previous years.
Dry Eye Frequency, Severity, and Etiology (Non-Lens Wearers)
Since the establishment of the definition of dry eye by the DEWS report in 2007, and through using new diagnostic tools, eyecare practitioners have grown to recognize that dry eye disease is one of the most common conditions observed in their practice (Lemp et al, 2007). It is estimated that nearly 1 in 3 patients presenting to eyecare clinics report symptoms of dry eye (Gayton, 2009), which is similar to the frequency estimates reported in our survey from 2009 to 2014. However, our respondents this year reported that, on average, 39% of their non-contact lens wearers have some form of dry eye, which is higher compared to what appeared in this report in 2014 (33% in 2014).
The percentage of these patients estimated to have evaporative dry eye (69%) has also increased from 2014 (59% in 2014) (Figure 1). The trends in dry eye research in general indicate that evaporative dry eye is more frequent than originally thought, which may be due to an increased awareness among practitioners of the need to examine the meibomian glands and to more frequent usage of clinical devices to measure lipid layer thickness (Lemp et al, 2015; Nichols K. et al, 2011).
Figure 1. Perceived major classifications of dry eye.
Indeed, meibomian gland dysfunction (MGD) is the primary cause of evaporative dry eye, and so evaluation of meibomian glands and the lipid layer of the tear film is likely being performed with greater frequency (Nelson et al, 2011). This year, our survey respondents reported that their preferred method in making a diagnosis of dry eye in non-lens wearers is the tear film breakup test (23%) (Figure 2). A greater percentage of respondents on average reported expressing meibomian glands in “most” of their non-lens-wearing dry eye patients (41%) when compared to 2014 (25% in 2014) (Figure 3). While it appears that the Schirmer’s/phenol red thread test is reported to be the preferred diagnostic test of less than 3% of respondents, remember that signs of aqueous deficient dry eye, such as a reduced tear meniscus height, may also be present. Most of us can agree that there is no one, single, gold standard diagnostic test, and practitioners often perform several tests to measure hallmarks of dry eye disease to aid in determining a dry eye diagnosis.
Figure 2. Preferred method for diagnosing dry eye in non-lens wearers.
Figure 3. Practitioners actively expressing meibomian glands in non-lens wearers who have dry eye.
Symptom assessment still has a vital role in making a diagnosis of dry eye, as it is reported to be the preferred diagnostic method for 20% of respondents (Figure 2); 60% of respondents reported that symptom assessment is “very important” in the diagnosis (Figure 4). These numbers are similar to previous years, and while a disconnect between signs and symptoms of dry eye occurs with high frequency, it is important to understand symptoms of dryness. Using a validated, specific questionnaire that delves deeper into a patient’s symptoms, impact on daily activities, and quality of life can provide useful information. In fact, up from only 16% in 2014, this year 30% of respondents report using a specific questionnaire to diagnose dry eye in non-lens-wearing patients. While used even more frequently in clinical research for stratifying patients into dry eye categories, validated questionnaires can be beneficial in monitoring treatment effectiveness and improvement in quality of life (Grubbs et al, 2014).
Figure 4. Importance of symptom assessment in diagnosing dry eye.
Managing Dry Eye in Non-Lens Wearers
Understanding the etiology behind aqueous deficient and evaporative dry eye can help in guiding treatments to alleviate symptoms and restore ocular homeostasis. Artificial tears are the one treatment reported by 46% of respondents to be used most frequently to treat aqueous deficient dry eye in non-lens wearers, whereas topical cyclosporine is used most frequently by 28% of respondents (Figure 5). These numbers remained consistent from 2014.
Figure 5. The one treatment used most frequently for treating dry eye in non-lens wearers.
For treating evaporative dry eye, warm compresses/lid hygiene take the lead as being used most frequently by 30% of respondents, followed by lipid-based tear supplements (21%), and artificial tears (22%) (Figure 5).
Contact Lens Dry Eye Frequency, Severity, Etiology, and Prognosis
As a contact lens is placed on the eye, the tear film structure is altered such that a pre- and post-lens tear film results. The pre-lens tear film is a thinned lipid layer with some of the aqueous-mucin components, whereas the post-lens tear film is a thinner version of the aqueous-mucin layer (Craig et al, 2013). This disruption and thinned tear film caused by the contact lens can lead to an increased evaporation rate of the tears (Guillon and Maissa, 2008). As a result, a previously asymptomatic patient may begin to experience symptoms of discomfort and dryness (Nichols and Sinnott, 2006). A more thorough explanation and review of contact lens discomfort was published in the Contact Lens Discomfort Workshop Report of the Tear Film and Ocular Surface Society in 2013 (Nichols J. et al, 2013).
The reported frequency in this year’s survey of dry eye among contact lens wearers is slightly higher (44%) compared to reported estimates from 2014 (38%), and it remains higher than for non-lens wearers (39%). This seems to reflect the contact lens-induced disruption to the tear film potentially contributing to increased tear evaporation, resulting in dry eye. Similarly, this year’s respondents reported that 66% of contact lens dry eye patients have evaporative dry eye (Figure 1), which is higher than what was reported in 2014 (57% in 2014). Respondents also reported that they believe 56% of their contact lens dry eye patients have meibomian gland disease, compared to 41% in 2014 (Table 1).
Table 1. Characteristics of dry eye in both non-lens wearers and in contact lens wearers.
This year, our respondents reported that they believe that 15% of their contact lens wearers permanently discontinue contact lens wear each year due to dryness and discomfort (Table 1), which is again similar to what we reported in 2014 (14% in 2014). Our hope is that we are able to keep more patients happy in contact lenses likely due to the wide range of daily disposable lenses and newer, more biocompatible materials available.
Virtually unchanged for the past four years, respondents reported that nearly two-thirds (63%) of contact lens dry eye patients have a mild form of the disease, whereas only 9% are severe (Figure 6). 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 (88%) (Figure 7).
Figure 6. Perceived dry eye disease severity.
Figure 7. Time of day for most severe symptoms.
In making a diagnosis of dry eye in contact lens wearers, 37% of respondents reported that their preferred method is symptom assessment (Figure 8), which is in contrast to the preferred method of diagnosis in non-lens wearers this year, reported by 23% of respondents to be the tear film breakup test. This is higher than what was reported in 2014 (28% in 2014), indicating that symptoms are playing a greater role in determining whether a contact lens wearer has dry eye.
Figure 8. Preferred method in making a diagnosis of contact lens dry eye.
Both the tear film breakup test and corneal staining were each reported to be preferred by 16% of respondents (Figure 8). Note that a higher percentage of respondents on average are reporting preferred methods that involve assessment of meibomian glands (7%) and meibomian gland expression (6%) when compared to 2014 (4% each in 2014). Similar to the report in 2014, 74% of respondents report symptom assessment as being “very important” in the diagnosis of dry eye in contact lens dry eye patients (77% in 2014) (Figure 4).
As lid wiper epitheliopathy (LWE) has gained some traction within the dry eye and contact lens dry eye communities (Bron et al, 2015; Jones et al, 2013), we asked eyecare practitioners if they actively check the lid margin for staining to assess LWE. The response was that 39% are checking the eyelids for this staining in “most patients,” and 38% are checking in “some dry eye patients” (Figure 9). LWE refers to a thickened area of staining on the lid wiper, the region of the upper palpebral conjunctiva that contacts the ocular surface during blinking (Korb et al, 2002). Some reports indicate that there is a higher rate of LWE in patients who have dry eye, as well as in those who wear contact lenses, due to increased friction during blinking as a result of poor lubrication (Korb et al, 2005; Korb et al, 2010; Yeniad et al, 2010; Pult et al, 2011).
Figure 9. Practitioners actively checking the lid margin for staining to assess for lid wiper epitheliopathy.
Managing Contact Lens-Related Dry Eye
With the wide assortment of contact lens materials and designs available on the market in ever expanding power availabilities, it is important to educate patients about their options and encourage the trial of more than one type of contact lens if discomfort is experienced with one material. Moreover, understanding the etiology behind dryness or symptoms of discomfort will aid in determining a treatment option for the greatest probability for success.
The one treatment option reported most frequently for contact lens patients who have dry eye disease is to refit into a lens with a more frequent replacement schedule (49%) (Figure 10). This is higher than what was reported in 2014, where 38% of respondents on average reported the most frequent treatment as refitting into a lens with more frequent replacement. This trend toward refitting into a daily disposable contact lens has continued to grow since 2014 and is perhaps even used more often as a first-line recommendation due to the perceived better comfort with such a lens modality. Indeed, 57% of respondents report that daily disposable silicone hydrogel contact lenses are the most efficacious at reducing dryness and discomfort (Figure 11). This, too, has increased from 2014 (45% in 2014), along with the number of daily disposable silicone hydrogel contact lenses available on the market. However, we still have relatively fewer options of daily disposable silicone hydrogel lenses in toric and multifocal toric prescriptions. The treatment option of changing care solution to treat contact lens discomfort continues to decrease (8% this year versus 10% in 2014), likely due to the preferred treatment of switching modalities so that care solution is not required (Figure 10).
Figure 10. The one treatment used most frequently for treating contact lens dry eye.
Figure 11. General lens category most efficacious at reducing dryness/discomfort.
The contact lens industry is poised on the edge of transforming contact lenses designed for correcting vision into the not-so-futuristic realm of smart lenses that can zoom with a blink, monitor glucose levels, or even record video. However, given the high frequency of dry eye disease, as eyecare practitioners we must be ready and equipped with treatments that will combat symptoms of discomfort that may arise when patients are fit with contact lenses.
One underlying consistent component of dry eye is down-stream inflammation (Stevenson et al, 2012; Hessen and Akpek, 2014). Studies investigating T-cell-mediated inflammation on the ocular surface have led to pending U.S. Food and Drug Administration (FDA) approval of a new treatment for dry eye that targets the inflammatory cascade, which will hopefully add to our repertoire of prescription treatments available.
In addition, included as part of the definition of dry eye, hyperosmolarity of the tear film is another pathogenic factor in the disease (Lemp et al, 2007). Devices capable of measuring tear osmolarity are clinically available; however, the complete utility of osmolarity measurements in contact lens wear is still under investigation.
In the meantime, we must continue asking about symptoms, examining the eyelids and meibomian glands, and assessing tear film stability to aid in our determination of whether any intervention is necessary. CLS
To obtain references for this article, please visit http://www.clspectrum.com/references and click on document #248.
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 an assistant vice president for industry research development and professor at the University of Alabama-Birmingham 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 from Johnson & Johnson Vision Care.