DRY EYE DX AND TX
SHOULD SLEEP SURVEYS BE STANDARD IN DRY EYE EXAMS?
KATHERINE M. MASTROTA, MS, OD, FAAO
Osleep, O gentle sleep,
Nature’s soft nurse, how have I frightened thee,
That thou no more will weigh my eyelids down,
And steep my senses in forgetfulness?
– History of Henry IV, Part II, William Shakespeare
Sleep. At every age, we need adequate, uninterrupted sleep for optimal wakeful functioning. Insufficient sleep is associated with a number of chronic diseases and conditions—such as diabetes, cardiovascular disease, obesity, and depression (Centers for Disease Control and Prevention [CDC], March 2015). But does compromised sleep impact the ocular surface?
One study from Japan concluded that sleep quality, or disturbance, is associated with dry eye disease (DED) (Kawashima et al, 2016). This does not surprise me in the least. We are familiar with ocular surface disease (OSD) in patients whose sleep is fractured by sleep apnea, often associated with Floppy Eyelid Syndrome (FES). The Kawashima study was a cross-sectional survey conducted mainly among young and middle-aged Japanese office workers who used visual display technology; no mention of body type was offered, limiting our knowledge of FES patients in the study, if any.
What is interesting to me in the aforementioned study was how sleep disturbance was identified and quantified. The authors in that study used the Pittsburg Sleep Quality Index (PSQI) questionnaire.
Assessing Sleep Quality
The Pittsburgh Sleep Quality Index is a self-report questionnaire that assesses sleep quality during a one-month time interval (Buysse et al, 1989). The PSQI measures the quality and patterns of sleep in older adults. It consists of 19 individual items, generating seven “component” scores: subjective sleep quality; sleep latency (i.e., how long it takes to fall asleep); sleep duration; habitual sleep efficiency (i.e., the percentage of time in bed that one is asleep); sleep disturbances; use of sleeping medication; and daytime dysfunction. This validated questionnaire differentiates “poor” from “good” sleep.
Patients may suffer from a number of sleep disorders, including dyssomnias (insomnia, hypersomnia, and sleep apnea), parasomnias (disorders characterized by abnormal or unusual behavior of the nervous system during sleep, such as sleepwalking and REM behavior disorder), sleep bruxism, and circadian rhythm sleep disorders. One study disclosed that adults who reported sleeping less than the recommended seven to nine hours per night were more likely to have difficulty performing many daily tasks (CDC, 2011).
The CDC recognizes insufficient/poor sleep as a public health problem. And, the Institute of Medicine has encouraged collaboration between the CDC and the National Center on Sleep Disorders Research to support development and expansion of adequate surveillance of the U.S. population’s sleep patterns and associated outcomes (CDC, Sept. 2015). Overall, there is a push to promote regular, healthy sleep habits, referred to as sleep hygiene. On its website, the National Sleep Foundation (2016) offers several suggestions to enhance patients’ sleep patterns. This begs the question: Should we incorporate a validated sleep survey into our dry eye exams?
Sleep and Dry Eye
Akin to DED, there are numerous validated global and targeted patient sleep/sleepiness/insomnia questionnaires available. Questionnaires can be selected to tease out sleep disorders in subsets of patients (e.g., pediatric, adolescent, and adult or obstructive sleep apnea suspects).
With novel technologies and emerging discovery, our evaluation of patients who have OSD has become more sophisticated and fine-tuned. Snippets of information supplement the profile of individual dry eye patients and add a target for therapeutic intervention.
Should we be prescribing lid hygiene and sleep hygiene? Patient sleep survey results may add the extra clinical sign/symptom that may be the “tipping point” for our OSD patients and how to manage those issues. CLS
For references, please visit www.clspectrum.com/references and click on document #250.
Dr. Mastrota is Clinical Director of the Omni Eye Surgery Center for Dry Eye Specialty Care. She is a consultant or advisor to Allergan, B+L, Bio-Tissue, OcuSoft, Paragon Bioteck, and Shire and is a stock shareholder of TearLab Corporation. Contact her at firstname.lastname@example.org.