Article

2018 REPORT ON DRY EYE DISEASES

The readers of Contact Lens Spectrum report their trends for dry eye diagnosis and treatment.

An estimated 40.9 million adults in the United States wear contact lenses.1 The number of indications for contact lens wear is growing, including for refractive correction, myopia control, therapeutic applications, and an aging population requiring multifocal contact lenses.2-4 The main reason for contact lens discontinuation is discomfort related to dryness, although more than 50% of those continuing to wear contact lenses also report symptoms of dryness.5,6

Since our last biennial dry eye report in 2016, the definition of dry eye has been updated, and a new U.S. Food and Drug Administration (FDA)-approved ophthalmic medication to treat signs and symptoms of dry eye disease has been released. Read on to learn about current diagnostic and treatment practice trends of eye-care practitioners, with an update on current etiologies behind dry eye disease.

This year’s survey for the dry eye report was conducted online from April through May 2018 and was completed by 92 eyecare practitioners currently practicing 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 the survey in detail and will provide comparisons to results from previous years.

DRY EYE FREQUENCY, SEVERITY, AND ETIOLOGY (NON-LENS WEARERS)

The Dry Eye Workshop II (DEWS II) report was published last year by the Tear Film and Ocular Surface Society (TFOS), which organized 150 clinical and basic research experts worldwide to review the literature and compile a comprehensive report.7 The report redefines dry eye as “...a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”8 Compared to the old definition, the multifactorial nature of the disease is still acknowledged; however, key terminology including neurosensory abnormalities, loss of homeostasis, and symptoms have been incorporated into the new definition.

While some reports indicate a rate of one in five patients presenting with self-reported symptomatic dry eye, it is estimated that nearly one in three patients present to clinics with both symptoms and signs of dry eye disease.9 This is similar to frequency estimates from 2009 to 2014; however, respondents this year reported that 42% of their non-contact lens wearers on average have some form of dry eye. This is higher compared to the reports from 2016 (39%) and 2014 (33%), perhaps reflecting an increased awareness.

While earlier reports on dry eye disease identified the two main categories of dry eye as aqueous deficient and evaporative, the current DEWS II report revised this classification to emphasize that these types of dry eye exist on a continuum scale rather than as exclusive diagnoses.8 The percentage of patients who have evaporative dry eye (65%) has decreased slightly from the 69% reported in 2016 (Figure 1).

Figure 1. Perceived major classifications of dry eye.

As mentioned, the new definition of dry eye contains terminology accounting for a broader range of symptoms and, in the clinical diagnosis schematic, divides presenting patients into symptomatic and asymptomatic.8 As if to reflect this, the 2018 survey respondents report that their preferred method for making a diagnosis of dry eye in non-lens wearers is assessment of symptoms (33%), whereas in 2016, the tear breakup test was preferred by 23% of respondents (Figure 2). Slightly fewer respondents on average reported expressing meibomian glands in “most” of their non-lens-wearing dry eye patients (35%) when compared to 2016 (41%) (Figure 3). Osmolarity testing remained steady as an infrequently preferred method for diagnosing dry eye in non-lens wearers this year (3%), and only 1% reported preferring MMP-9 testing, which is an indicator of inflammatory status on the ocular surface.10

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.

The diagnostic tests recommended by the DEWS II report include both symptomatology assessment as well as either tear breakup time, tear osmolarity, or ocular surface staining as preferred methods.11 While these tests are the minimum recommendation, additional testing should be performed to identify dysfunctional aspects of the ocular surface to guide both diagnoses and treatment plans.

As noted earlier, symptom assessment still plays a vital role in making a diagnosis of dry eye. In addition, 63% of respondents reported that symptom assessment is “very important” in making their diagnosis (Figure 4). A response of “essential–diagnosis only if symptoms present” was added to the survey this year, and 14% of respondents reported that they would make a diagnosis of dry eye only if symptoms were reported.

Figure 4. Importance of symptom assessment in diagnosing dry eye. *Numbers rounded.

MANAGING DRY EYE IN NON-LENS WEARERS

Understanding the etiology behind aqueous-deficient and evaporative dry eye can be crucial in formulating successful treatment plans to alleviate symptoms and to restore ocular homeostasis. This year, a higher number of respondents reported using artificial tears/lubricants (62%) most frequently for treating aqueous-deficient dry eye in non-lens wearers, compared to 46% in 2016. This may be accounted for by fewer respondents (11%) reporting using Restasis (topical cyclosporine, Allergan) this year compared to 2016 (28%) and by 7% of respondents reporting that they use Xiidra (topical lifitegrast, Shire). Note: Lifitegrast ophthalmic solution 5.0% was approved in the United States in July 2016 for treating signs and symptoms of dry eye disease.12

For treatment of evaporative dry eye, warm compresses/lid hygiene continue to be reported most frequently (31% of respondents), followed by artificial tears/lubricants (28%) and lipid-based tear supplements (19%) (Figure 5).

Figure 5. One treatment used most frequently for treating dry eye in non-lens wearers. *Numbers rounded.

CONTACT LENS DRY EYE FREQUENCY, SEVERITY, ETIOLOGY, AND PROGNOSIS

Successful lens wear is largely dependent on the integrity of the tear film; pre-existing dysfunction of the tears increases the risk of complications and discomfort, as placement of a contact lens on the eye disrupts the tear film into a pre- and post-lens tear film. The outer, pre-lens tear film is a thinned lipid layer that contains some of the aqueous-mucin components and coats the surface of the contact lens, while the post-lens tear film is a thinner version of the aqueous-mucin layer that allows transmission of oxygen to the cornea.13 Soft contact lens wearers have higher rates of tear evaporation, even those who are asymptomatic.14 As a result of this evaporation, a previously asymptomatic patient may begin to experience symptoms of discomfort and dryness.15

This year, the reported frequency of dry eye among contact lens wearers is relatively similar (43%) to reported estimates from 2016 (44%); it is also on par with this year’s dry eye frequency estimates for non-lens wearers (42%). In addition, this year’s respondents reported perceiving that 65% of their contact lens dry eye patients have evaporative dry eye (Figure 1), which is almost identical to that reported in 2016 (66%).

Interestingly, the perceived classifications of dry eye for both non-lens and lens wearers were the same in survey responses this year. Similarly, respondents reported that they believe that 55% of their contact lens dry eye patients have meibomian gland disease compared to 56% in 2016 (Table 1).

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

Current respondents reported that 18% of contact lens wearers permanently discontinue contact lens wear each year due to dryness and discomfort, which is slightly higher than the report in 2016 (15%) and in 2014 (14%). However, dropout rates reported by clinical studies vary due to differences in methodology, location, and year in which the study was conducted, and the current reported rate from survey respondents is lower than what is typically seen in the literature. A 2013 study by Dumbleton et al surveyed contact lens wearers and reported a 23% permanent dropout rate, with the primary reasons being discomfort and dryness.16 A more recent study conducted in the United Kingdom by Sulley and colleagues identified the dropout rate in the first year of lens wear as 26%, citing poor vision and discomfort as contributing factors.17

Virtually unchanged during the past four years, respondents reported that nearly two-thirds (60%) of contact lens-wearing dry eye patients have a mild form of the disease, whereas 11% are severe (Figure 6). And, in making a diagnosis of dry eye in contact lens wearers, 37% of respondents report that their preferred method is symptom assessment (Figure 7), which, as noted earlier, is also the preferred method in non-lens wearers. This is unchanged from what was reported in 2016 (37%), indicating that symptoms are still playing a major role in determining whether a contact lens wearer has dry eye.

Figure 6. Perceived dry eye disease severity. *Numbers rounded.

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

The tear film breakup test was reported to be preferred by 17% of respondents, whereas corneal staining and meibomian gland assessment were each reported as preferred by 9% of respondents (Figure 7). Note that a lower percentage of respondents on average are reporting corneal staining as a preferred method (9%) when compared to 2016 (16%).

When rating importance of symptoms in making a diagnosis of dry eye in lens wearers, 69% of respondents report symptom assessment as being “very important,” whereas 13% report it as being “essential–diagnosis only if symptoms present” (Figure 4).

Lid wiper epitheliopathy (LWE) refers to lissamine green staining on the upper eyelid margin or lid wiper area, the region of the palpebral conjunctiva that contacts the ocular surface during blinking.18 It has been previously identified as a sign seen more commonly in contact lens wearers who are symptomatic as well as in symptomatic dry eye patients.19-22 However, a recent prospective longitudinal cohort study by Stahl et al in 20 subjects failed to find an association between LWE and contact lens discomfort.23

This year, 35% of respondents reported actively checking for lid margin staining in “most patients” compared to 39% in 2016 (Figure 8). However, only 13% report actively checking in “most contact lens patients,” and 14% do not actively check for lid margin staining.

Figure 8. Practitioners actively checking the lid margin for staining to assess for lid wiper epitheliopathy.

MANAGING LENS-RELATED DRY EYE

With the wide assortment of contact lens materials and designs available on the market, it is important to educate patients on their options. Moreover, understanding the etiology behind dryness or symptoms of discomfort will aid in determining a treatment option for the greatest chance for contact lens wear continuation.

The one treatment option that was reported most frequently by this year’s survey respondents for contact lens patients who have dry eye disease is to refit into a lens with a more frequent replacement schedule (52%); this is slightly higher compared to what was reported in 2016 (49%) (Figure 9).

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

This trend toward refitting into a daily disposable contact lens has continued to grow since 2014 and is perhaps even used as a first-line recommendation due to the perceived better comfort with such a lens modality. Indeed, 64% of respondents report that daily disposable silicone hydrogel contact lenses are the most efficacious at reducing dryness and discomfort (Figure 10). This, too, has increased from 2016 (57%) and from 2014 (45%) along with the number of daily disposable silicone hydrogel lenses available in spherical, toric, and multifocal prescriptions on the market.

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

The treatment options of changing care solution, use of rewetting drops, and refit into different contact lens material (same replacement schedule) were all each reported by 11% of respondents (Figure 9). While the FDA clinical trials for Xiidra (topical lifitegrast) were performed in non-contact lens wearers, 2% of respondents reported prescribing it for treating contact lens dry eye.

CONCLUDING THOUGHTS

Contact lenses are becoming more highly utilized not only for refractive correction, but for other purposes as well including myopia control and delivery of therapeutics.24,25 However, given the still relatively high frequency estimates of dry eye disease in our patients (42% in non-lens wearers, 43% in lens wearers), eyecare practitioners must be ready and equipped with treatments that will combat symptoms of discomfort that may arise when patients are fit with contact lenses.

In the meantime, eyecare practitioners must continue asking about symptoms, examining the eyelids and meibomian glands, and assessing tear film stability to aid in their determination of whether any intervention is necessary. CLS

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