dry eye disease 1 DRY EYE DISEASE What We Know About It Today and Its Importance for Optometry Arthur B. Epstein, OD, FAAO Paul M. Karpecki, OD, FAAO Katherine M. Mastrota, MS, OD, FAAO Walter O. Whitley, OD Sponsored by UUntitled-2ntitled-2 1 44/25/16/25/16 111:371:37 AAMM 2 dry eye disease INTRODUCTION Although critically important to the practice of optometry, a sophisticated understanding of dry eye disease (DED) is a relatively recent development. Just 20 years ago, DED was a poorly understood entity for which there was a significant controversy with respect to diagnosis.1 This picture began to change with the publication of the “Report of the National Eye Institute/Industry Workshop on Clinical Trials in Dry Eyes.”1 Like the subsequent DEWS Report, the NEI/Industry Workshop brought together and gave structure to our then-current knowledge of DED and laid the groundwork for future research and understanding. Thanks to significant interest—including commercial interest—the field has grown rapidly. So much has happened that a second DEWS Report (DEWS II) is now being undertaken. TOWARDS A NEW Dry eye is a multifactorial UNDERSTANDING disease of the tears and Arthur B. Epstein, OD, So how far have we come? And ocular surface that results FAAO, FABCO, FBCLA, what does a new understanding DPNAP, is co-founder of in symptoms of discomfort, Phoenix Eye Care, PLLC, mean for optometric practice? visual disturbance, and where he heads the Ocular We can start by looking back. Surface Disease Center tear film instability with and serves as the Center’s In 1995, the NEI/Industry potential damage to director of clinical research. Workshop defined dry eye as the ocular surface. It is “a disorder of the tear film due accompanied by increased Paul M. Karpecki, OD, to tear deficiency or excessive FAAO, heads the Advanced osmolarity of the tear film Ocular Surface Disease evaporation, which causes damage and inflammation of the Center and is director to the interpalpebral ocular surface 2 of clinical research at ocular surface. the Koffler Vision Group, and is associated with symptoms Lexington, KY. of ocular discomfort.”1 This definition recognized two primary etiologies (aqueous deficiency Katherine M. Mastrota, MS, OD, FAAO, is Regional and excessive evaporation), a sign Practice Ambassador/ (ocular surface “damage,” primarily Director, Omni Eye Surgery New York Dry Eye/Ocular detectable by staining [Figure 1]), Wellness Center. and a symptom (discomfort) but was otherwise silent with respect to causes, effects, or corollaries of the 1 Walter O. Whitley, OD, condition. is Director, Optometric Twelve years after the NEI/ Services at Virginia Eye FIGURE 1 Fluorescein stain Consultants, Norfolk, VA. Industry Workshop, the DEWS shows inferior corneal staining Report was able to offer a more suggestive of DED tissue damage. robust definition: (Photo courtesy Dr. Karpecki.) Untitled-2 1 4/25/16 11:38 AM dry eye disease 3 This definition makes clear that 30 inflammation and hyperosmolarity Women are hallmarks of the condition and that visual disturbance, tear 25 Men film instability, and ocular surface Overall damage are characteristic clinical 20 findings of DED. The inclusion of visual disturbance and the 15 emphasis on tear film instability brings the definition closer to our (%) Prevalence 10 current understanding. While much has been learned since its 5 publication, the DEWS Report gave us a useful platform for 0 thinking about the diagnosis of 21-34 35-44 45-54 55-64 65-84 DED. The DEWS Report has Age in years been enormously influential in shaping both research and clinical FIGURE 2 Prevalence of dry eye symptoms found in the Beaver Dam practice. Offspring Study 2005–2008. (Adapted from Paulsen Reference 4.) In the following pages, we’ll look at advances in understanding DED since the DEWS Report was published, and its impact on for estimating the level of DED When stratified by sex, the diagnosis and day-in, day-out in the general population of US effect of age on dry eye differed optometric practice. While still adults.4 between men and women in incomplete, our knowledge has In that study, baseline data BOSS. In men, the estimated significantly expanded. were collected between 2005 and prevalence was similar among 2008 from BOSS participants aged all age groups and there was no PREVALENCE 21 to 84 years via a questionnaire observed effect of age (P = 0.91); We have said that DED is on health history, medication critically important to optometry, use, risk factors, and quality of and part of what makes DED so life. Whether a BOSS subject “As we have learned from the important is the sheer number had DED was determined by of people affected. To put DED self-report of symptom frequency BOSS data and from experience prevalence in perspective, we and intensity or reported use of in our own clinics, a DED normally think of glaucoma as a artificial tears. highly prevalent eye disease. In In an initial publication of diagnosis should not be ruled quantitative terms, the prevalence these baseline data, Paulsen and out simply because a patient is of open-angle glaucoma in the US coworkers reported an overall is approximately 3 million (almost prevalence of DED symptoms young—particularly if the patient 2% of the US population).3 of 14.5%—or nearly 30 million How prevalent is DED? people—with rates significantly is a contact lens wearer.” Although studies vary based higher in women than men —PAUL M. KARPECKI, OD, FAAO on the definition of DED (17.9% vs. 10.5%, P < 0.0001) and a population studied, the (Figure 2).4 Interestingly, although recently published report on DED has traditionally been DED prevalence among 3257 associated with aging, in the while in women, prevalence participants in the long-term, overall BOSS group, symptoms increased with age (P = 0.02), ongoing Beaver Dam Offspring were also prevalent among younger although this interaction was Study (BOSS) provided a baseline subjects.4 not significant (Figure 2).4 Using UUntitled-2ntitled-2 1 44/25/16/25/16 111:381:38 AAMM 4 dry eye disease different criteria, Schaumberg and Perimenopausal women weren’t medical aspect of DED. Patients coworkers’ important work found the only patients, but if you asked come to us with DED because an age-adjusted prevalence of dry a fellow clinician to describe the they are uncomfortable and/ eye syndrome of 7.8% in women typical DED patient, that was or unable to achieve clear, stable 50 and older in a study population what you were likely to hear. vision, impacting productivity between 49 and 89 years of age.5 The BOSS data also aligns well and some visual-related activities In a separate study, Schaumberg with our clinical impression that, of daily living (e.g., reading and and colleagues also reported that although perimenopausal women driving). dry eye was common in men still make up a significant fraction It’s also important to recall (aged 50 to 99 years), with an age of DED sufferers, younger women that DED can be a side effect adjusted prevalence of 4.34% in and men of all ages are increasingly of ocular surgery or topical men 50 and older.6 susceptible (Figure 2). medications. It no longer So, clearly, DED prevalence Although the evidence is still surprises an eye care physician rates vary depending on the largely anecdotal, it is no longer when DED crops up following study population and criteria, considered unusual to encounter ocular surgery10 or in medically but our clinical experience 20-somethings with DED. treated glaucoma patients, where (which admittedly is skewed by Whether this is because there is Baudouin and others have shown our status as clinicians with an more DED at younger ages or that preservatives—particularly because we are more conscious benzalkonium chloride (BAK)— of DED and therefore more used in intraocular pressure- “The impact of dry eye on an willing to diagnose it in younger lowering medications can produce patients is an open question. But significant damage to the ocular individual’s perception of their there is precedent for large scale surface.11 And diabetes, a growing social/environmental changes threat to global health, can health is substantial and of to impact vision. Consider, for produce ocular surface changes as importance as a public health example, the enormous increase well as the better known retinal in myopia in young people that complications.12 problem.” we have witnessed over the last 2 Whether the patient initially generations.7 presented for spectacles, contact —JA PAULSEN AND COLLEAGUES, 2014 lenses, surgery, a glaucoma check, DED AND OPTOMETRIC or any other medical condition, PRACTICE what matters in the end is how well interest in DED) is that the 14.5% DED can produce a range of the patient can see—and vision prevalence rate in the BOSS is a negative impacts on the patients starts with the ocular surface. reasonable estimate and possibly whom optometrists see every day. Because it impacts both vision even an underestimate of the The typical optometric practice and comfort, DED can be the number of Americans affected. is likely to offer contact lenses, enemy of patient satisfaction and The BOSS data also conform and for many practices, contact optometric success—or it can be an to another aspect of our clinical lenses are central to their success. opportunity for practice growth. experience: that a DED diagnosis Changes to the tears, ocular should not be ruled out simply surface, and lid margin can reduce BURDEN OF DISEASE because a patient is young— wearing time—and may even lead Leaving aside its potential particularly if the patient is a to contact lens drop out.8 effects on contact lens wear and contact lens wearer.