Longitudinal Examination of Frequency of and Risk Factors for Severe Dry Eye Symptoms in US Veterans

Abstract

IMPORTANCE Dry eye syndrome is a common condition that affects millions of individuals. Many cross-sectional studies have evaluated risk factors for dry eye severity, but few have assessed risk factors or symptom progression over time. OBJECTIVES To assess symptom progression in dry eye syndrome and determine risk factors associated with severe symptoms at 1 year. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study was conducted from October 1, 2013, to April 30, 2015, among patients at the Miami Veterans Affairs Hospital with a wide variety of dry eye symptoms and signs (ranging from none to severe). MAIN OUTCOMES AND MEASURES Change in dry eye symptom severity during 1 year, as assessed by responses to dry eye symptom questionnaires administered at the initial visit and 1 year later, as well as baseline risk factor analysis for severe dry eye symptoms at 1 year, defined as a Dry Eye Questionnaire 5 score of 12 or more. RESULTS Of the 120 patients (mean [SD] age, 64 [11] years; 109 male and 11 female), 26 of 58 (44.8%) with either no symptoms or mild or moderate symptoms at baseline progressed to more severe symptoms at 1 year, while 46 of 62 patients (74.2%) with severe symptoms at baseline reported that severe symptoms persisted at 1 year. Baseline ocular risk factors for severe dry eye symptoms at 1 year included more severe dry eye symptoms, ocular pain, and neuropathic pain-like ocular symptoms. Nonocular risk factors included sleep disturbances (eg, sleep apnea and insomnia), mental health status (eg, posttraumatic stress disorder and depression), nonocular pain, and medications (eg, anxiolytics and analgesics). In a multivariable analysis, the most significant risk factors were sleep apnea (odds ratio [OR], 3.80; 95% CI, 1.00-14.49; P = .05), Dry Eye Questionnaire 5 score (OR, 1.15; 95% CI, 1.02-1.30; P = .02), and posttraumatic stress disorder score (OR, 1.04; 95% CI, 1.01-1.08; P = .02). CONCLUSIONS AND RELEVANCE Patients with severe dry eye symptoms and ocular pain at baseline were more likely to have persistent severe dry eye symptoms on 1-year follow-up. Furthermore, nonocular risk factors that have been associated with dry eye cross-sectionally, such as psychiatric comorbidities and nonocular pain, were also associated with severe dry eye symptoms at 1 year. Although this cohort was limited to US veterans, which may not be generalizable to other populations, our results suggest that pain perception and severity are important when evaluating and managing dry eye.

Comorbidities and Prescribed Medications in Patients With or Without Dry Eye Disease: A Population-Based Study

“…The results are in agreement with previously reported DED-associated comorbidities and further expand the list of conditions that may be considered to be associated with DED. [3][4][5][6][7]9,29,34 Additionally, the new study reports on the therapeutic treatments undertaken by beneficiaries having various comorbidities, both with and without DED, and thus may provide additional context to the risk/benefit consideration of common treatments for the DED and at-risk-of-DED populations. For example, evidence was found of conditions in which DED associations may be attributable to ocular manifestations of a primary disease (eg, thyroid imbalance, rosacea).…”

“…2,4,34 Similarly, anxiolytic prescriptions for beneficiaries were 2-fold higher (DED: 21.7 newly diagnosed, 23.7% prevalent; non-DED: 14.7 newly diagnosed, 15.3% prevalent) than the proportion of beneficiaries with anxiety disorders (DED: 11.4 newly diagnosed, 12.4% prevalent; non-DED: 6.8 newly diagnosed, 7.5% prevalent). Because both antidepressant and anxiolytic medications are associated with a higher proportion of patients with DED, 5,17,22,29,36,[54][55][56] their use by patients with DED, or at risk for DED, should be ascertained even in the absence of a clinical diagnosis of depression and/or anxiety. Closer alignment of conditions to associated prescribed medications was found for beneficiaries with sleeping disorders, including sleep apnea (the proportion of sleep medication prescriptions is w70%-90% of the proportion of beneficiaries with sleep disorders across all groups).…”

Sleep Disorders are a Prevalent and Serious Comorbidity in Dry Eye

“…Ong et al 50 assessed symptom progression in DED and determined ocular and nonocular risk factors associated with severe symptoms at 1 year in a longitudinal study of 120 veterans (mean age, 64 years). Nonocular risk factors included sleep disturbances (e.g., sleep apnea and insomnia), mental health status (e.g., posttraumatic stress disorder and depression), nonocular pain, and medications (e.g., anxiolytics and analgesics).…”

Evidence that dry eye is a comorbid pain condition in a U.S. veteran population

“… 27 From a symptom perspective, many patients with DE with sensations of ocular dryness endorse other pain complaints that are frequently found in those with nonocular pain, namely hot-burning pain, hyperalgesia (eg, sensitivity to wind), and allodynia (eg, sensitivity to light). 21 These symptoms are often chronic 32 and do not completely respond to therapies targeting the tear film and ocular surface. 11 , 41 …”

“…2 Symptoms of DE include a wide range of dysesthesias described as unpleasant including “dryness,” “burning,” and “aching,” 21 and many individuals report a chronic symptom course. 32 Signs of DE are varied and can include decreased tear production, increased tear evaporation, and ocular surface disruption. 1 Similar to nonocular chronic pain conditions, DE symptoms often do not correlate with clinical signs of DE.…”