Allam Khalid et al, 2021;5(3):838–844. International Journal of Medicine in Developing Countries https://doi.org/10.24911/IJMDC.51-1609345198

ORIGINAL ARTICLE Awareness and knowledge toward dry eye disease among Saudi Arabian population Allam Khalid1, Aladhyani Abdulwahab2, Alharbi Aseel3, Alshngeetee Ayshah4*, Alharbi Khalid5, Aljuaid Mohammed6, Alshowigi Njood4, Alghamdi Omar7, Alnuman Rawand8, Alkhaldi Saleh9

ABSTRACT Background: Dry eye syndrome (DES), also known as keratoconjunctivitis sicca (KCS), affects the tear film either by decreasing the production of tears or by increasing the evaporation of tears. Also, the syndrome is multifactorial, where patients usually complain of a variety of symptoms, including dry eyes, burning sensa- tion, pain, and photophobia. The present study aimed at measuring the awareness and knowledge regarding DES among the population of Saudi Arabia via a questionnaire. Methodology: Healthy Saudi adults (male and female) would answer an online questionnaire delivered by social media to measure the awareness of KCS among patients aged from 18 to 55 years, where healthcare providers were not allowed to participate in the study. Results: In this study, we received 451 responses to our questionnaire. Almost half of the participants were aged between 18 and 25 years, while 28.6% were aged between 36 and 55 years. Females represented a slightly higher percentage of the sample (57.9%). Asthma was the most commonly reported chronic condition with a prevalence of 9.1%, while hypertension prevalence was 6.2%. Moreover, most of the participants indi- cated that they had not had any ocular surgery (82%), while 11.8% indicated that they had refractive surgery and 5.1% had other surgery. Conclusion: We had observed a poor attitude toward DES among the Saudi Arabian population, including that most of the participants did not have a routine ophthalmologist visit and tended to use electronic devices for a long time without a break knowing about their risk Keyword: Dry eye, DES, complication, knowledge, treatment, causes.

Introduction

Dry eye syndrome (DES) known as keratoconjunctivitis prevalence of DES varies between different regions and sicca is a condition that affects the tear film either by time; however, it ranges between 9.5% and 90% [6-8]. decreasing the production of tears or by increasing This difference may be because DES is affected by the the evaporation of tears. Also, the syndrome is populations’ geographic location and characteristics multifactorial, and it may occur due to either aqueous besides the variation in the diagnostic criteria used in tear deficiency or meibomian gland dysfunction, and those studies. However, similarly, the prevalence of DES the syndrome may occur due to both [1,2]. Moreover, is higher in Asian countries than in Western countries [9]. the patient complains of various symptoms, including On the other hand, the prevalence of DES among other dry eyes, burning sensation, pain, and photophobia [1]. The signs have a different course; it may come as a mild transient to persistent irritation [2]. Moreover, dry Correspondence to: Alshngeetee Ayshah eye disease is a common ocular surface disorder that *Imam Mohammed Ibn Saud Islamic University, Riyadh, has a significant impact on the patients’ vision-related Saudi Arabia. quality of life. Therefore, it is considered a public health Email: [email protected] problem [3,4]. Female gender, age more than 56, current Full list of author information is available at the end of the article. smoking, and history of diabetes mellitus are some of Received: 30 December 2020 | Accepted: 19 January 2021 the significant risk factor of DES [5]. Furthermore, the

© IJMDC. https://www.ijmdc.com 838 Awareness and knowledge toward dry eye disease

cities in Saudi Arabia showed that it was 45.1% among while hypertension prevalence was 6.2%, thyroid gland the Riyadh governorate population (except the capital) disease had a prevalence of 5.8%, and 5.5% reported [10]. Furthermore, 32.1% of the Al-Ahsa population having a high cholesterol level. However, 67% of the showed symptomatic DES [5]. participants indicated having no medical conditions Moreover, we observed that the number of patients who (Figure 1). visited the ophthalmology clinic with complaints of DES 73.4% of the participants did not take any medications, was going up, so we aimed to measure the awareness while painkillers were the most common medications and knowledge regarding DES among the Saudi Arabia taken by participants (11.5%), followed by other population to evaluate the level of health education medicines (11.1%) and hypertensive medications (5.8%) regarding DES. (Figure 2). Subjects and Methods Moreover, most participants indicated that they had not had any ocular surgery (82%), while 11.8% indicated This study is a cross-sectional study based on a having refractive surgery and 5.1% had other surgeries community-based, self-administer questionnaire that (Figure 3). assessed the knowledge and awareness of dry eye among Attitude toward dry eye: Most participants reported that the general population in Saudi Arabia via an online they used spectacles (42.8%) and 38.1% of them indicated questionnaire. A pilot study was conducted to validate that artificial tears and sunglasses were used by 31% of the questionnaire which was distributed through social the participants. However, 24.4% of the participants media in Saudi Arabia. The sample size was calculated stated that they did not use any of the options. Moreover, using the formula n = z2pq\d2. With a confidence level of using electronic devices for a long time without a break 95%, an estimated proportion of 50%, and a 5% level of and eye rub were the most common habits related to the precision, the minimum sample size was calculated to be samples’ eye (66.1% and 59.0%, respectively). Other 385. Inclusion criteria included all adults, healthy adults habits include eye makeup (21.1%), smoking (16.2%), aged 18 years and above of both genders. Those who and exposure of the eyes to air (14.2%). Furthermore, were below 18 years of and who worked as healthcare most of the sample indicated that they did not have a providers were excluded. An online, self-administered routine ophthalmologist visit (88.9%) (Table 2). questionnaire was distributed through social media. The questionnaire included five sections; the first section is Knowledge toward DES: More than half of the sample a consent form to join the research; the second section indicated that they had known about DES (53.7%), while is related to demographic data; the third section contains questions of past medical and medication history. The fourth section includes questions about caring for eyes, Table 1. Demographic factors. and the fifth section questions assessing the awareness and knowledge regarding DES. Data analysis was Frequency Percent conducted using Statistical Package for the Social Age 18-25 209 46.3 Sciences version 23. Frequency and percentages were 26-35 84 18.6 used to display categorical variables. A chi-squared test was used to test for the presence of an association 36-55 129 28.6 between categorical variables. Independent t-test and Over 55 29 6.4 analysis of variance test were utilized to test for the Gender Male 190 42.1 association within continuous variables. The level of Female 261 57.9 significance was set at p < 0.05. Occupation Housewife 99 22.0 Results Health sector 110 24.4 Education sector 127 28.2 Demographic factors: In this study, we received 451 Engineering 23 5.1 responses to our questionnaire. Almost half of the participants were aged between 18 and 25 years, while Economy and business 63 14.0 administration 28.6% were aged between 36 and 55 years. Females represented a slightly higher percentage of the sample Security and military 15 3.3 (57.9%). Considering the participants’ occupations, Science and research 7 1.6 most of the participants (28.2%) were in the education arts 7 1.6 sector, 24.4% were in the health sector, and 22% were Province Central 170 37.7 housewives. Moreover, most of the sample was from the western and central regions (45% and 37.7%, Western 203 45.0 respectively) (Table 1). Southern 18 4.0 Eastern 17 3.8 Chronic conditions: Asthma was the most commonly reported chronic condition with a prevalence of 9.1%, Northern 43 9.5

839 Awareness and knowledge toward dry eye disease

Figure 1. Chronic conditions.

Figure 2. Medications taken by participants.

Figure 3. Medical history of ocular surgery.

70.1% of them thought that DES is widely spread in causes of DES. Considering symptoms of DES, stinging Saudi Arabia (Table 3). and burning sensations were the most known symptoms Moreover, the most known causes of DES by participants reported by the participants (55.7% for each), followed were prolonged use of electronic devices (71.6%), by foreign body sensation (48.1%), redness (46.8%), and weather conditions (56.5%), lacrimal gland disorder eye strain (43.2%). In comparison, 18.4% did not know (31.7%), thyroid gland disorder (31.5%), rheumatoid about the symptoms. Furthermore, 38.8% of the sample arthritis (31.5%), and refractive surgery (30.2%), while indicated that blurred vision could be a complication of 16.6% of participants reported that they did not know the DES, followed by corneal abrasion (35.3%) and 32.8%

840 Awareness and knowledge toward dry eye disease

Table 2. Attitude toward dry eye.

Frequency Percent Do you use any of these? No medications 110 24.4 Spectacles 193 42.8 Sunglasses 140 31.0 Contact lens 71 15.7 Artificial tears 172 38.1 Eye ointments 17 3.8 Do you do any of the Eye rub 266 59.0 following? Use electronic devices for a 298 66.1 long time without a break Eye makeup 95 21.1 Smoking 73 16.2 Expose eyes directly to air 64 14.2 None 52 11.5 Routine ophthalmologist Yes 50 11.1 visit No 401 88.9

Table 3. Knowledge about DES.

Frequency Percent Do you know DES? Yes 242 53.7 No 209 46.3 Do you think DES is widely spread in saudi Yes 316 70.1 arabia (SA) No 135 29.9

indicated not knowing about the complications of DES. we received 451 responses from different regions of Taking a break every 20 minutes when using electronic Saudi Arabia. In this study, we found that 66.1% of the devices was the most common advice to reduce the participants indicated that they used electronic devices prevalence of DES (69%), followed by wearing for a long time without a break. This is similar to the sunglasses (45.9%) and avoiding going in bad weather finding of Kalakattawi [11], in which she found that most conditions (44.1%); however, 20.2% did not know about of her sample watched TV and used mobile phones or the the prevention of DES (Table 4). computer for an extended period daily (86.5%). Watching TV or other electronic devices without rest can lead to DES The relationship between demographic factors and in which most research shows that those often complain attitude and knowledge toward DES: In Table 5, we of eye strain, eye fatigue, burning, redness, dry eye, and found that older participants, especially those above 55 blurred vision [12]. The problem found in this study about years, tended more to have routine ophthalmologist visits the habit of watching electronic devices for a long time than younger participants (p = 0.000); however, they is not related to common knowledge where 71% of the had a lower knowledge about the causes of DES (p = sample were aware that this habit could cause DES and 0.03). Otherwise, age had no significant effect on other that stopping it or taking a break every 10 minutes can be variables. On the other hand, gender had a significant the solution for DES. However, they had it. Therefore, we effect on knowledge toward DES. However, females found that there is a gap between the knowledge and attitude indicated that they knew more about DES; they did not among populations. Moreover, smoking and air pollution choose I do not know in all other aspects of knowledge in have been suggested to be risk factors for developing DES a manner higher than males. in many studies. Smoking can predispose the eye to tear Discussion film instability and there is a correlation between smoking and dry eye [13]. In our study, only 16.1% indicated that Dry eye is a significant tear deficiency disorder that they are smokers, which is lower than that reported in other affects millions of people worldwide. It is a distressing studies [11]. Almost a quarter of the sample was aware problem that is often overlooked and under-diagnosed. of the dangers of smoking on developing DES. Weather conditions and lacrimal gland disorder are some of the In this study, we aimed to measure the awareness and causes of DES that is known to more than one-third of the knowledge regarding DES among Saudi Arabia. Therefore,

841 Awareness and knowledge toward dry eye disease

Table 4. Causes and prevention of DES.

Frequency Percent Causes of DES Smoking 116 25.7 long use of electronic devices 323 71.6 Diabetes 83 18.4 thyroid gland disorder 142 31.5 rheumatoid arthritis 142 31.5 refractive surgery 136 30.2 lacrimal gland disorder 143 31.7 weather conditions 255 56.5 do not know 75 16.6 Symptoms of DES Redness 211 46.8 foreign body sensation 217 48.1 Stinging 251 55.7 burning sensation 251 55.7 photophobia 107 23.7 blurred vision 156 34.6 eye strain 195 43.2 secretions 58 12.9 do not know 83 18.4 Complications of DES affects daily activities 130 28.8 eye inflammation 127 28.2 corneal abrasion 159 35.3 blurred vision 175 38.8 corneal ulcer 82 18.2 do not know 148 32.8 Prevention of DES take a break every 20 minutes when using electronic 311 69.0 devices use artificial tears to moisturize eyes 177 39.2 wearing sunglasses 207 45.9 avoid smoking & negative smoking 143 31.7 place electronic devices below eye level 143 31.7 avoid going out in bad weather conditions 199 44.1 do not know 91 20.2

sample. Moreover, we found that older participants had and there is a need to improve it, especially in aspects of more tendencies to have routine ophthalmologist visits than complication and prevention. the younger population. The high prevalence of DES can This study has certain limitations, which include explain this in older participants found in many other dry depending on an online-self reported questionnaire eye studies [14,15]. On the other hand, gender did not affect as a tool for collecting data. This type of device has this attitude, which contrasts with other studies that showed the advantage of collecting a large sample in a shorter that prevalence of DES was higher in females [5,11,16]; time. However, it affects the study by having some bias therefore, they should go to routine ophthalmologist visits problems where some participants may not understand the male who is not found in this study. Moreover, 53.7% the questions or try to be more moral by choosing the of the sample indicated that they knew DES. However, answers they thought the authors need. Moreover, online 16.6% of participants stated that they did not know the tools mean the limitation of a questionnaire on those who causes of DES, 18.4% about the symptoms, 32.8% about can use the online application; therefore, most of our complications, and 20.2% about prevention. Therefore, population was younger. On the other hand, this is one we suggest that however, participants may have some of the first studies which aimed to assess the knowledge knowledge about DES. This knowledge is not complete, about DES among the Saudi Arabian citizens.

842 Awareness and knowledge toward dry eye disease

Table 5. Relationship between demographic factors and attitude and knowledge toward DES.

Age Gender 18-25 26-35 36-55 Over 55 Male Female Routine ophthalmologist visit Yes 9.6% 7.1% 10.9% 34.5% 10.0% 11.9% No 90.4% 92.9% 89.1% 65.5% 90.0% 88.1% p-value 0.000* 0.531 Do you know DES? Yes 54.1% 56.0% 50.4% 58.6% 46.3% 59.0% No 45.9% 44.0% 49.6% 41.4% 53.7% 41.0% p-value 0.793 0.008 Knowledge about the Causes of DES No 78.0% 90.5% 86.0% 89.7% 73.7% 90.4% Yes 22.0% 9.5% 14.0% 10.3% 26.3% 9.6% p-value 0.03* 0.000* Knowledge about Symptoms of DES No 80.4% 82.1% 82.9% 82.8% 73.7% 87.4% Yes 19.6% 17.9% 17.1% 17.2% 26.3% 12.6% p-value 0.936 0.00* Knowledge about Complications of DES No 67.8% 63.1% 68.0% 69.0% 55.3% 75.7% Yes 32.2% 36.9% 32.0% 31.0% 44.7% 24.3% p-value 0.863 0.000* Knowledge about Prevention of DES No 77.5% 82.1% 85.3% 65.5% 72.1% 85.4% Yes 22.5% 17.9% 14.7% 34.5% 27.9% 14.6% p-value 0.071 0.000*

Conclusion Author details Allam Khalid1, Aladhyani Abdulwahab2, Alharbi Aseel3, We had noted a poor attitude toward DES among the Saudi Alshngeetee Ayshah4, Alharbi Khalid5, Aljuaid Mohammed6, Arabian population, including that most of the participants Alshowigi Njood4, Alghamdi Omar7, Alnuman Rawand8, did not have routine ophthalmologist visits and tended Alkhaldi Saleh9 to use electronic devices for a long time without a break 1. Department of Vitreoretinal Surgery, King Saud Medical knowing about their risk. Considering knowledge, we City, Riyadh, Saudi Arabia found that more than half of the sample indicating knowing 2. Shaqra University, Shaqra, Saudi Arabia DES; however, we noted a poor knowledge considering 3. King Abdulaziz University, Jeddah, Saudi Arabia complications and prevention of DES. 4. Imam Mohammed ibn Saud Islamic University, Riyadh, Saudi Arabia List of Abbreviations 5. Ibn Sina National College, Jeddah, Saudi Arabia DES Dry eye syndrome 6. Umm Al-Qura University, Mecca, Saudi Arabia KCS Keratoconjunctivitis sicca 7. King Fahad Hospital-Albaha Ophthalmology Department, SA Saudi Arabia Albaha, Saudi Arabia Conflict of interest 8. Jouf University, Jouf, Saudi Arabia 9. Ophthalmology Department, King Saud Medical City, The authors declare that there is no conflict of interest Riyadh, Saudi Arabia regarding the publication of this article. References Funding None. 1. Tsubota K, Toda I, Yagi Y, Ogawa Y, Ono M, Yoshino K. Three different types of dry eye syndrome. Cornea. Consent to participate 1994;13(3):202–9. https://doi.org/10.1097/00003226- Written informed consent was obtained from all the 199405000-00002 participants. 2. Horwath-Winter J, Berghold A, Schmut O, Floegel I, Solhdju V, Bodner E, et al. Evaluation of the clinical course of dry Ethical approval eye syndrome. Arch Ophthalmol. 2003;121(10):1364–8. The study was approved by the Ethics Committee at King https://doi.org/10.1001/archopht.121.10.1364 Saud Medical City on 15/11/2020, Ref # H-01-R-053.

843 Awareness and knowledge toward dry eye disease

3. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo C-K, 10. Yasir ZH, Chauhan D, Khandekar R, Source C, Varghese S. et al. TFOS DEWS II definition and classification report. Prevalence and determinants of dry eye disease among Ocul Surf. 2017;15(3):276–83. https://doi.org/10.1016/j. 40 years and older population of Riyadh (except capital), jtos.2017.05.008 Saudi Arabia. Middle East Afr J Ophthalmol. 2019; 4. Grubbs JR Jr, Tolleson-Rinehart S, Huynh K, Davis 26(1):27–32. https://doi.org/10.4103/meajo.MEAJO_ RM. A review of quality of life measures in dry eye 194_18 questionnaires. Cornea. 2014;33(2):215–8. https://doi. 11. Kalakattawi RM, Al Rubaie SS, Alslaqi RM, Al-Shehri LA, org/10.1097/ICO.0000000000000038 Alzahrani AA. Knowledge and Practice Regarding Dry Eye 5. Alshamrani AA, Almousa AS, Almulhim AA, Alafaleq AA, among General Population in Western Region of Saudi Alosaimi MB, Alqahtani AM, et al. Prevalence and risk Arabia. Journal of Basic and Clinical Pharmacy. 2018;9(1). factors of dry eye symptoms in a Saudi Arabian population. 12. Phadatare SP, Momin M, Nighojkar P, Askarkar S, Middle East Afr J Ophthalmol. 2017;24(2):67–73. https:// Singh KK. A comprehensive review on dry eye disease: doi.org/10.4103/meajo.MEAJO_281_16 diagnosis, medical management, recent developments, 6. Bakkar MM, Shihadeh WA, Haddad MF, Khader YS. and future challenges. Adv Pharm. 2015 https://doi. Epidemiology of symptoms of dry eye disease (DED) in org/10.1155/2015/704946 Jordan: a cross-sectional non-clinical population-based 13. Xu L, Zhang W, Zhu XY, Suo T, Fan XQ, Fu Y. Smoking and study. Cont Lens Anterior Eye. 2016;39(3):197–202. the risk of dry eye: a Meta-analysis. Int J Ophthalmol. https://doi.org/10.1016/j.clae.2016.01.003 2016;9(10):1480–6. 7. Hashemi H, Khabazkhoob M, Kheirkhah A, Emamian 14. Albietz JM. Prevalence of dry eye subtypes in clinical MH, Mehravaran S, Shariati M, et al. Prevalence of dry optometry practice. Optom Vis Sci. 2000;77(7):357–63. eye syndrome in an adult population: dry eye in an adult https://doi.org/10.1097/00006324-200007000-00010 population. Clin Exp Ophthalmol. 2014;42(3):242–8. 15. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for https://doi.org/10.1111/ceo.12183 dry eye syndrome. Arch Ophthalmol. 2000;118(9):1264– 8. Lee AJ, Lee J, Saw SM, Gazzard G, Koh D, Widjaja D, et 8. https://doi.org/10.1001/archopht.118.9.1264 al. prevalence and risk factors associated with dry eye 16. Shanti Y, Shehada R, Bakkar MM, Qaddumi J. Prevalence symptoms: a population-based study in Indonesia. and associated risk factors of dry eye disease in 16 Br J Ophthalmol. 2002;86(12):1347–51. https://doi. northern West bank towns in Palestine: a cross-sectional org/10.1136/bjo.86.12.1347 study. BMC Ophthalmol. 2020;20(1):26. https://doi. 9. Um SB, Kim NH, Lee HK, Song JS, Kim HC. Spatial org/10.1186/s12886-019-1290-z epidemiology of dry eye disease: findings from South Korea. Int J Health Geogr. 2014;13(1):31. https://doi. org/10.1186/1476-072X-13-31

844