BONUS FEATURE
AN EXAMINATION OF THE PRESBYOPIC PATIENT WITH DRY EYE
Insights into the role of media use, hormones, and more. BY JONATHAN D. ANDREWS, OD
t is estimated that 2 billion of the 13% for those 80 and older.5 Although meibomian glands. Blink rate nearly 7.8 billion people on the literature reviews have not suggested a reduction with near work is well planet are presbyopic.1 An estimat- positive correlation between presbyopia documented. Multiple studies have ed 16 million US adults have been and dry eye disease, the aging popula- come to the conclusion that spon- diagnosed with dry eye disease,2 tion primarily constitutes the majority taneous eye blink rates are reduced Ibut some reports indicate that nearly of patients who report symptoms con- irrespective of type of reading plat- half of all US adults experience dry eye sistent with those of dry eye. form.6,7 It is hypothesized that blink signs and symptoms.3 What factors should practitioners inhibition with near work may arise The prevalence of dry eye increases consider when they treat presbyopic from high cognitive demand or from with each passing decade of life starting patients with dry eye, and why does a low-legibility condition that requires at age 40,4 and the prevalence of dry eye this age group differ from others? I’ll us to perform prolonged fixation symptoms in women increases from tackle these questions here. while acquiring visual information.8 14% at 50 years of age to 22% for those A recent study in which I was 80 and older. In men, the prevalence THE EFFECTS OF DEVICE USE involved as a researcher identified of dry eye symptoms increases from Blinking helps our eyelids a negative correlation between 7% between 60 and 69 years of age to to mechanically discharge the time spent on digital devices and
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meibomian gland function and struc- 4 14 ture and the symptomatology of dry eye disease. Researchers from five 3 10.5 clinics across the United States and Canada used members of Old Order 2 7 Amish populations as a control group because of their limited exposure UNC Scores to digital devices. This multicenter 1 SPEED Scores 3.5 study of 64 patients found that digital device use for more than 2 hours per 0 0 day resulted in statistically significant 0-1 2-5 6-9 10-12 0-1 2-5 6-9 10-12 morphologic changes in meibomian Time Reported on Digital Devices (Hours) Time Reported on Digital Devices (Hours) glands (gland atrophy) and increased symptoms of dry eye disease (Figure).9 Figure. University of North Carolina Dry Eye Management Scale scores versus hours reported on digital devices (left). SPEED 9 We also found that meibum quality scores versus hours reported on digital devices (right). and expressibility were both negative- that number is expected to climb to of any phoria (distance or near) was ly affected with more than 2 hours 13.6 networked devices per person 28.37% and that the prevalence of per day of digital device use, and we by 2022.11 With an array of digital phoria significantly increased with demonstrated a negative correlation devices and the diverse nature of a age. The prevalence of near exophoria between the amount of digital person’s visual demands, it is impor- and near esophoria was 25.96% and device use per day and the quality of tant to remember the role that 0.47%, respectively.13 expressible meibum.9 accommodation can play in one’s Clinical research has shown that visual comfort. 90% of ocular misalignments are ACCOMMODATIVE DEMAND Some patients do not fixate accu- greater at near than distance.14 Fifty AND OCULAR ALIGNMENT rately at the point of interest, and percent of patients who have unre- Some consumers spend more their vergence angle may correspond solved dry eye symptoms, despite than 50% of their days—more than with a point slightly closer or farther all proper dry eye treatment proto- 12 hours—connected to media, away. In today’s digital workplace, cols, have at least three symptoms according to The Nielsen Total accommodative demand is an ever- that could be related to ocular Audience Report.10 Specifically, adults changing carousel. One study of misalignment.15 Furthermore, in between ages 50 and 64 years spend 23 patients found that their mean patients whose primary complaint is an average of 13 hours, 50 minutes viewing distance while using their late-day dry eye, symptoms seem to connected to media, which is twice smartphones was 20.3 cm when seat- lessen when they are prescribed pris- the amount spent by adults between ed and 16.4 cm when lying down.12 matic correction in spectacle lenses ages 35 and 49 years.10 The average viewing distance for an (neurolenses, eyeBrain Medical).16 The average American has iPad or tablet is around 38 cm, a lap- In a study of 360 patients who were approximately eight networked top 50 cm, and a desktop monitor prescribed contour prism for 90 days, devices, and with 5G on the verge of around 70 cm. Another study of 3,314 93% had a reduction in symptoms of being the next mainstream normal patients found that the prevalence computer vision syndrome.15 Presbyopic adults spend a majority of their waking hours viewing digital AT A GLANCE media, and they should undergo a thorough assessment of their ocular
s alignment and refractive demands The prevalence of dry eye increases with each passing decade of life in addition to a standard dry eye starting at age 40. workup.
s Adults between age 50 and 64 years spend on average almost 14 hours THE ROLE OF HORMONES connected to media. Sex hormones are constantly changing in the presbyopic adult. s Fifty percent of patients who have unresolved dry eye symptoms have Both estrogens and androgens influence the synthesis and compo- at least three symptoms that could be related to ocular misalignment. nents of the tear film, including the lipid, aqueous, and mucin layers. The
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1.Presbyopia expected to impact billions worldwide. Review of Optometric Business. www.reviewob.com/presbyopia-expected-to-impact-billions- worldwide-3/:~:text=Presbyopia%20affects%20nearly%201.7%20 billion,to%202.1%20billion%20by%202020. Accessed September 23, 2020. 2. Farrand KF, Fridman M. Stillman IÖ, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years FIFTY PERCENT OF PATIENTS and older. Am J Ophthalmol. 2017;182:90-98. 3. Dry eye syndrome: symptoms and causes. All About Vision. June 2019. www.allaboutvision.com/conditions/dryeye-syndrome.htm. Accessed September 11, 2020. WHO HAVE UNRESOLVED DRY EYE 4. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334-365. 5. Matossian C, McDonald M, Donaldson KE, Nichols KK, Maclver S, Gupta PK. Dry eye disease: consideration for women’s health. J Womens Health SYMPTOMS, DESPITE ALL PROPER (Larchmt). 2019;28(4):502-514. 6. Chu CA, Rosenfield M, Portello JK. Blink patterns: reading from a computer screen versus hard copy. Optom Vis Sci. 2014;91(3):297-302. 7. Argilés M, Cardona G, Pérez-Cabré E, Rodríguez M. Blink rate and incomplete DRY EYE TREATMENT PROTOCOLS, blinks in six different controlled hard-copy and electronic reading conditions. Invest Ophthalmol Vis Sci. 2013;90(5):482-487. 8. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol. 2018;3(1):e000146. HAVE AT LEAST THREE SYMPTOMS 9. Andrews JD. The impact of digital devices on meibomian gland structure and function. Paper presented at: The American Academy of Optometry Annual Meeting; October 23-27, 2019; Orlando, FL. 10. The Nielsen Total Audience Report: April 2020. The Nielsen Company. April 20, 2020. www.nielsen.com/us/en/insights/report/2020/the-nielsen-total- THAT COULD BE RELATED TO audience-report-april-2020/. Accessed September 11, 2020. 11. IoT has quietly and quickly changed our lives. NCTA: The Internet & Television Association. February 1, 2019. www.ncta.com/whats-new/iot-has- quietly-and-quickly-changed-our-lives. Accessed September 14, 2020. OCULAR MISALIGNMENT. 12. Yoshimura M, Kitazawa M, Maeda Y, Mimura M, Tsubota K, Kishimoto T. Smartphone viewing distance and sleep: an experimental study utilizing motion capture technology. Nat Sci Sleep. 2017;9:59-65. 13. Hashemi H, Nabovati P, Yekta A, Ostadimoghaddam H, Behnia B, Khaba- meibomian glands have androgen- review of HRT showed significant zkhoob M. The prevalence of strabismus, heterophorias, and their associated factors in underserved rural areas of Iran. Strabismus. 2017;25(2):60-66. binding receptors that play a part in improvement of dry eye (tear pro- 14. Indiana University School of Optometry. Cross-coupling of accom- the synthesis and secretion of lipids. duction and tear breakup time) at modation and convergence (AC/A and CA/C). In: Oculomotor Functions & Estrogen actually causes a decrease in 1 month, but a nonsignificant impact Neurology. 2004. 15. Karpecki PM. The dry eye misalignment. Review of Optometry. 19 lipid production, and increased levels at 3 and 6 month follow-ups). 2018;155(8):80-81. of estradiol are believed to be a risk 16. Survey of 360 neurolens patients after 90 days of treatment. Data on file, 17,18 eyeBrain Medical. factor for dry eye. However, the BE PREPARED TO IDENTIFY 17. Peck T, Olsakovsky L, Aggarwal S. Dry eye syndrome in menopause and relationship between sex hormone AND MANAGE DRY EYE perimenopausal age group. J Midlife Health. 2017;8(2)51-54. 18. Suzuki T, Schirra F, Richards SM, et al. Estrogen and progesterone control levels and dry eye treatments remains Dry eye is increasingly prevalent as of gene expression in the mouse meibomian gland. Invest Ophthalmol Vis Sci. controversial, as the effects of estro- the average person is consumed by 2008;49(5);1797-1808. 19. Dang A, Nayeni M, Mather R, Malvankar M. Hormone replacement therapy gen and androgen therapy to treat digital device use during the majority for dry eye disease pateints: systemiatic review and meta-analysis. Can J dry eye are not well understood. of his or her waking hours. It is crucial Ophthalmol. 202;5;1;3-11. Hormone replacement therapy to perform a comprehensive evalua- 20. Liu C, Liang K, Jiang Z, Tao L. Sex hormone therapy’s effect on dry eye syn- drome in postmenopausal women. Medicine (Baltimore). 2018;97(40):e12572. (HRT) has shown mixed results in its tion of any patient who presents with 21. Sullivan DA, Sullivan BD, Evans JE, et al. Androgen deficiency, effect on dry eye symptoms across dry eye symptoms, including both a meibomain gland dysfunction, and evaporative dry eye. Ann N Y Acad Sci. 2002;966;211-222. a number of studies.19,20 In women refractive and a binocular assessment with abnormally low testosterone of the patient’s vision system. Primary levels, men on androgen blockers, eye care providers should be equipped JONATHAN D. ANDREWS, OD and patients with androgen insen- with the ability to diagnose and treat n Owner, Andrews Eye Corporation, Lancaster, sitivity syndrome, topical androgen dry eye for the presbyope while insti- Pennsylvania treatments are widely considered tuting interventions using a compre- n [email protected] beneficial.21 A systematic literature hensive ophthalmologic approach. n n Financial disclosure: None
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