Eye-care professionals have neglected dry eye disease (DED) for decades. The reasons for this neglect are many, including: DED patients are demanding and hard to please; patients require significant chair time and thus have a negative impact on practice efficiency; they are difficult to diagnose accurately; reimbursement concerns are real for dry eye tests; few effective treatments exist.

THERE’S NO AVOIDING IT

That said, it is critical to understand that, untreated, DED also becomes more difficult to treat.

We know this because we are beginning to understand the importance and clinical relevance of dry eye. In the United States alone, an estimated 20 to 30 million patients have a diagnosis of DED.¹

DED affects individuals in most age groups: 76% of eye-care professionals reported an increase in dry eye symptoms in patients 18 to 34 years old.² But its prevalence increases as people age. The major factor determining an increase in dry eye prevalence over the next 20 years is the size of the population at risk for dry eye. Ten thousand baby boomers turn 65 years old every day until 2030.³

In our country, the prevalence of DED among adults 21 to 49 years old is approximately 14%, and 15.2% in those older, according to the 2014 Beaver Dam Offspring study.¹ The estimate of DED in postmenopausal women is 14 million. By 2020, says Menopause.Org , the U.S. will have about 50 million postmenopausal women.⁴ As for men over age 50, Schaumburg et al in 2009 found prevalence was 1.8%; it is expected to rise to 2.80% by 2030.⁵

SIGN OF THE TIMES

We now understand that today’s lifestyle has increased the risk of DED. Seventy-three percent of contact lens users report dissatisfaction or discontinuation due to symptoms.⁶ The multiscreen lifestyle has contributed to an increase in DED. Six in 10 adults spend five or more hours/day on digital devices and one in four children spend three hours/day using digital devices.⁷ Eighty-nine percent of eye-care professionals suspect modern technology contributes to dry eye symptoms, according to a Harris Poll study.⁸

Ocular surgery has been well studied and documented to increase DED. Forty-eight percent of post-LASIK patients reported dryness for six months and there is an increased risk in post-cataract patients, especially those with incisional astigmatic corneal surgery.²

DED has a significant effect on the quality of life. Severe dry eye ranked similar to severe angina and dialysis with regards to patient’s complaints on the impact on quality of life.⁹ Even mild to moderate dry eye affects success with contact lens wear, work performance, willingness to drive at night and enjoyment of outdoor activities.¹⁰ DED patients have significant discomfort and loss of quality of vision.

FINALLY, SOLUTIONS ARE ON THE WAY

There is hope for DED patients. Industry has shown an increased interest in the last several years in its diagnostic and treatment endeavors and clinicians are beginning to realize the impact that DED has on patients — who want better treatments than the palliative therapy of artificial tears alone.

Refractive and cataract surgeons are realizing what corneal specialists have known for many years: DED is a common cause of patient dissatisfaction after surgery. Twenty-eight percent of dissatisfied LASIK patients and 15% of dissatisfied multifocal IOL patients attribute this unhappiness — which does not include impact on vision — to DED.^11,12 Glaucoma specialists now realize that most of their chronic patients have some type of ocular surface disease and it is impacting their vision.¹³

New diagnostics tests have recently been approved. These tests will improve DED diagnosis accuracy and efficiency. Tests such as tear osmolarity, IL1 RA, and MMP-9 as well as meibomian gland imaging will be valuable tools to diagnose DED and monitor the effect of treatment.

Until recently there was only one approved DED medication (cyclosporine, Restasis, Allergan). New therapies such as lifitegrast (Xiidra, Shire), lid thermal pulsation (TearScience) and intranasal neurostimulation (TrueTear, Allergan) will improve our ability to treat DED. In addition, there are at least 15 products in clinical development for diagnosis or treatment of DED.

LET’S GET SERIOUS

The time has come for all eye-care professionals to screen and treat DED. The tools are here: new, more accurate diagnostic methods, new treatments for better outcomes (hence happier patients), reimbursement for testing and ways to make DED clinics profitable.

But it comes down to this: Diagnosing and treating DED is the right thing to do for our patients who’ve endured this condition for far too long. OM

REFERENCES

1. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the Beaver Dam Offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157:799-806.
2. Shire. Modern technology and a multi-screen lifestyle viewed as important factors in rising prevalence of dry eye disease. Oct 17, 2016. Available: https://tinyurl.com/ybd3q3dq . Accessed: June 19, 2017.
3. Pew Research Center. Baby Boomers Retire. Dec. 29, 2010. Available: http://www.pewresearch.org/fact-tank/2010/12/29/baby-boomers-retire/ . Accessed June 19, 2017.
4. North American Menopause Society. Chapter 1: Overview of Menopause. Available: https://tinyurl.com/y9soh4zr . Accessed June 19, 2017.
5. Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye disease among US men: estimates from the Physicians’ Health Studies. Arch Ophthalmol. 2009 Jun; 127: 763-768.
6. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007;26:168-174.
7. 2015 Digital Eye Strain Report. The Vision Council. 2016.
8. Vision Monday. Harris Poll National Eye C.A.R.E. Study Cites Multi-Screen Lifestyle as Key Factor in Rising Prevalence of Dry Eye. https://tinyurl.com/y8dhu8h2 . Accessed June 20, 2017.
9. Buchholz P, Steeds CS, Stern LS, et al. Utility assessment to measure the impact of dry eye disease. Ocul Surf. 2006;4:155-161.
10. Hirsch JD. Considerations in the pharmacoeconomics of dry eye. Manag Care. 2003;12:33-38.
11. Levinson BA, Rapuano CJ, Cohen EJ, et al. Referrals to the Wills Eye Institute cornea service after laser in situ keratomileusis: reasons for patient satisfaction. J Cataract Refract Surg. 2008;34:32-39.
12. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009;35:992-997.
13. Sheppard J. Starting your dry eye center of excellence. Ophthalmology Management. June 2016. ophthalmologymanagement.com/issues/2016/june-2016/starting-your-dry-eye-center-of-excellence Accessed June 22, 2017.

 

EDWARD HOLLAND, M.D. Edward J. Holland, MD is the Director of Cornea Services at Cincinnati Eye Institute and Professor of Ophthalmology at the University of Cincinnati. He attended the Loyola-Medical School in Chicago and trained in Ophthalmology at the University of Minnesota. He completed a fellowship in cornea and external disease at the University of Iowa, and then a second fellowship in ocular immunology at the National Eye Institute. Dr. Holland has a national and international reputation for his knowledge and expertise in the field of cornea and external disease. He is frequently invited to attend lectures both nationally and internationally. Dr. Holland is the author of over 230 articles in peer review journals and has co-edited four editions of “Cornea,” the most widely read textbook on corneal disease and surgery.