Prevalence and Risk Factors of Dry Eye Syndrome in a United States Veterans Affairs Population

doi:10.1016/j.ajo.2011.02.026

American Journal of Ophthalmology

Volume 152, Issue 3, September 2011, Pages 377-384.e2

https://doi.org/10.1016/j.ajo.2011.02.026 Get rights and content

Purpose

To evaluate the prevalence of dry eye syndrome (DES) and its associated risk factors in a US Veterans Affairs population receiving ocular care services.

Design

Retrospective study.

Methods

settings: Patients were seen in the Miami and Broward Veterans Affairs eye clinics between 2005 and 2010. patients population: Patients were divided into cases and controls with regard to their dry eye status (cases = ICD9 code for DES plus dry eye therapy; controls = patients without ICD9 code plus no therapy). main outcome measures: The prevalence of DES and its associated risk factors.

Results

A total of 16 862 patients were identified as either a dry eye case (n = 2056) or control (n = 14 806). Overall, 12% of male and 22% of female patients had a diagnosis of DES, with female gender imparting a 2.40 increased risk (95% confidence interval [CI] 2.04–2.81) over male gender. Several medical conditions were found to increase DES risk including post-traumatic stress disorder (odds ratio [OR] 1.97, 95% CI 1.75–2.23), depression (OR 1.91, 95% CI 1.73–2.10), thyroid disease (OR 1.81, 95% CI 1.46–2.26), and sleep apnea (OR 2.20, 95% CI 1.97–2.46) (all analyses adjusted for gender and age). The use of several systemic medications, including anti-depressant medications (OR 1.97, 95% CI 1.79–2.17), anti-anxiety medication (OR 1.74, 95% CI 1.58–1.91), and anti–benign prostatic hyperplasia medications (OR 1.68, 95% CI 1.51–1.86), was likewise associated with an increased risk of DES.

Conclusions

The prevalence of DES was found to be high in both men and women in our eye care population. This is the first study to demonstrate that in a veteran population, several diagnoses were significantly associated with DES, including post-traumatic stress disorder and depression.

Section snippets

Study Population

Patients seen in the Miami and Broward Veterans Affairs eye clinics between July 15, 2005 and July 15, 2010 were included in this analysis. Patients seen in Veterans Affairs clinics consist of ex-military personnel but do not include or represent all former military recruits. Patients seen in other Veterans Affairs outpatient clinics during this time period were not included as a preliminary analysis revealed that non–eye care professionals did not use the ICD9 code for DES. Patients were

DES Prevalence

The crude period prevalence (number of dry eye cases over 5-year period divided by all patients seen during that time period) of dry eye syndrome in our veteran population was 10% (n = 2056/20 731).

Risk Factor Analysis of Demographic Characteristics

Excluding discordant cases (n = 3869), a total of 16 862 patients were identified as being either a dry eye case (n = 2056) or control (n = 14 806). The period prevalence for these patients (number of dry eye cases over 5-year period divided by a denominator, which excluded patients with discordant

Discussion

The goal of this study was to use the Veterans Affairs administrative database to estimate the prevalence of DES in a veteran population and to examine which medical diagnosis and systemic medications were associated with an increased risk of DES. Several previous studies have similarly reported on DES prevalence and risk factors and we wished to compare our findings with those of other US and international populations. As the scope of DES in the Veterans Affairs population has not previously

Anat Galor, MD, is an Assistant Professor at the Bascom Palmer Eye Institute, Miami, Florida, and a staff physician at the Miami VAMC. She completed an ophthalmology residency at the Cleveland Clinic Cole Eye Institute, followed by a uveitis fellowship at Wilmer Eye Institute and a cornea fellowship at Bascom Palmer Eye Institute. Dr. Galor's research interests focus on understanding the pathophysiology and improving treatment outcomes of ocular surface conditions including dry eye syndrome,

References (34)

H. Brewitt et al.
Dry eye disease: the scale of the problem
Surv Ophthalmol
(2001)
O.D. Schein et al.
Prevalence of dry eye among the elderly
Am J Ophthalmol
(1997)
C.A. McCarty et al.
The epidemiology of dry eye in Melbourne, Australia
Ophthalmology
(1998)
M. Uchino et al.
Prevalence of dry eye disease among Japanese visual display terminal users
Ophthalmology
(2008)
R.M. Schiffman et al.
Utility assessment among patients with dry eye disease
Ophthalmology
(2003)
K. Rajagopalan et al.
Comparing the discriminative validity of two generic and one disease-specific health-related quality of life measures in a sample of patients with dry eye
Value Health
(2005)
D.A. Schaumberg et al.
Prevalence of dry eye syndrome among US women
Am J Ophthalmol
(2003)
C. Yazdani et al.
Prevalence of treated dry eye disease in a managed care population
Clin Ther
(2001)
M.T. Bergmann et al.
The effect of a diuretic (hydrochlorothiazide) on tear production in humans
Am J Ophthalmol
(1985)
The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007)
Ocul Surf
(2007)

D.A. Schaumberg et al.

Epidemiology of dry eye syndrome

Adv Exp Med Biol

(2002)

C.G. Begley et al.

Characterization of ocular surface symptoms from optometric practices in North America

Cornea

(2001)

S.E. Moss et al.

Prevalence of and risk factors for dry eye syndrome

Arch Ophthalmol

(2000)

K. Bandeen-Roche et al.

Self-reported assessment of dry eye in a population-based setting

Invest Ophthalmol Vis Sci

(1997)

B. Munoz et al.

Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study

Arch Ophthalmol

(2000)

E.M. Chia et al.

Prevalence and associations of dry eye syndrome in an older population: the Blue Mountains Eye Study

Clin Experiment Ophthalmol

(2003)

T. Hikichi et al.

Prevalence of dry eye in Japanese eye centers

Graefes Arch Clin Exp Ophthalmol

(1995)

Cited by (164)

Decoding and reconstructing disease relations between dry eye and depression: a multimodal investigation comprising meta-analysis, genetic pathways and Mendelian randomization
2024, Journal of Advanced Research
The clinical presentations of dry eye disease (DED) and depression (DEP) often comanifest. However, the robustness and the mechanisms underlying this association were undetermined.
To this end, we set up a three-segment study that employed multimodality results (meta-analysis, genome-wide association study [GWAS] and Mendelian randomization [MR]) to elucidate the association, common pathways and causality between DED and DEP.
A meta-analysis comprising 26 case−control studies was first conducted to confirm the DED-DEP association. Next, we performed a linkage disequilibrium (LD)-adjusted GWAS and targeted phenotype association study (PheWAS) in East Asian TW Biobank (TWB) and European UK Biobank (UKB) populations. Single-nucleotide polymorphisms (SNPs) were further screened for molecular interactions and common pathways at the functional gene level. To further elucidate the activated pathways in DED and DEP, a systemic transcriptome review was conducted on RNA sequencing samples from the Gene Expression Omnibus. Finally, 48 MR experiments were implemented to examine the bidirectional causation between DED and DEP.
Our meta-analysis showed that DED patients are associated with an increased DEP prevalence (OR = 1.83), while DEP patients have a concurrent higher risk of DED (OR = 2.34). Notably, cross-disease GWAS analysis revealed that similar genetic architecture (r_G = 0.19) and pleiotropic functional genes contributed to phenotypes in both diseases. Through protein−protein interaction and ontology convergence, we summarized the pleiotropic functional genes under the ontology of immune activation, which was further validated by a transcriptome systemic review. Importantly, the inverse variance-weighted (IVW)-MR experiments in both TWB and UKB populations (p value <0.001) supported the bidirectional exposure-outcome causation for DED-to-DEP and DEP-to-DED. Despite stringent LD-corrected instrumental variable re-selection, the bidirectional causation between DED and DEP remained.
With the multi-modal evidence combined, we consolidated the association and causation between DED and DEP.
Age Associations with Dry Eye Clinical Signs and Symptoms in the Dry Eye Assessment and Management (DREAM) Study
2023, Ophthalmology Science
To evaluate how increasing age is associated with dry eye disease (DED) signs and symptoms in the Dry Eye Assessment and Management (DREAM) study. This study was undertaken to better understand how DED signs and symptoms differ across decades of life with goals to help assess detection and treatment of DED.
Secondary analysis of the DREAM study.
One hundred twenty, 140, 185, and 90 participants aged < 50, 50 to 59, 60 to 69, and ≥ 70 years, respectively.
We performed a secondary analysis of data from the DREAM study, a multicenter randomized clinical trial, to evaluate the effect of omega-3 fatty acid supplementation for the treatment of DED. At baseline, 6 months, and 12 months follow-up, participants underwent an assessment of DED symptoms and signs using Ocular Surface Disease Index, Brief Pain Inventory, tear break-up time (TBUT) (in seconds), Schirmer test with anesthesia (mm/5 minutes), conjunctival staining, corneal staining, meibomian gland dysfunction evaluation, and tear osmolarity (mOsm/l). Multivariable generalized linear regression models were used to compare DED symptoms and signs across the 4 age groups among all participants and by sex.
Scores of DED symptoms, individual signs, and composite scores of DED signs.
Among 535 patients with DED, increasing age was significantly associated with worse TBUT (P = 0.01), corneal staining (P < 0.001), a composite severity score of DED signs (P = 0.007), and tear osmolarity (P = 0.001). Similar significant differences were found across 4 age groups of 334 women in TBUT, corneal staining score, composite severity score of DED signs, and tear osmolarity (all P < 0.05) but not in men.
We found that corneal staining, TBUT, tear osmolarity, and a composite severity score of DED signs were significantly more severe with increasing age in women but not in men; worsening symptoms did not increase with increasing age.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
A cross-sectional study of non-modifiable and modifiable risk factors of dry eye disease states
2023, Contact Lens and Anterior Eye
The present study aimed to determine the relationship of non-modifiable (rheumatoid arthritis, thyroid diseases, and arterial hypertension) and modifiable risk factors (diuretics, antidepressants, or anxiolytics tranquilizers) with the different Dry Eye Disease (DED) diagnostics in a sample adjusted by antihistamines intake.
A total of 400 participants were included in a cross-sectional study. Before a dry eye examination, participants completed an online self-administered OSDI questionnaire with six additional questions about possible DED risk factors. The Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS-II) diagnostic criteria of DED was used. Based on signs and/or symptoms, participants were divided into 4 groups: No DED, Pre-clinical DED, Predisposition to DED and DED. Since the symptom scores would have been altered by the use of antihistamines, the analysis of each outcome was adjusted for this factor, where those participants were assumed to be symptomatic.
Multivariable logistic regression found thyroid disease as a possible risk factor for DED (OR 4.53, 95 % CI 1.04–19.73; Fisher’s exact, p = 0.044; Crameŕs V = 0.140, p = 0.024). No association was found between the studied parameters and Pre-clinical DED (Fisher’s exact, all p ≥ 0.398; Crameŕs V, all p ≥ 0.242) or Predisposition to DED (Fisher’s exact, all p ≥ 0.065; Crameŕs V, all p ≥ 0.031).
Participants with thyroid disease were more likely to develop DED, therefore, thyroid disease could be a risk factor for DED.
TFOS lifestyle: Impact of societal challenges on the ocular surface
2023, Ocular Surface
Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.
TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface
2023, Ocular Surface
Many factors in the domains of mental, physical, and social health have been associated with various ocular surface diseases, with most of the focus centered on aspects of dry eye disease (DED). Regarding mental health factors, several cross-sectional studies have noted associations between depression and anxiety, and medications used to treat these disorders, and DED symptoms. Sleep disorders (both involving quality and quantity of sleep) have also been associated with DED symptoms. Under the domain of physical health, several factors have been linked to meibomian gland abnormalities, including obesity and face mask wear. Cross-sectional studies have also linked chronic pain conditions, specifically migraine, chronic pain syndrome and fibromyalgia, to DED, principally focusing on DED symptoms. A systematic review and meta-analysis reviewed available data and concluded that various chronic pain conditions increased the risk of DED (variably defined), with odds ratios ranging from 1.60 to 2.16. However, heterogeneity was noted, highlighting the need for additional studies examining the impact of chronic pain on DED signs and subtype (evaporative versus aqueous deficient). With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and DED symptoms.
Estimates of dry eye disease in Saudi Arabia based on a short questionnaire of prevalence, symptoms, and risk factors: The Twaiq Mountain Eye Study I
2023, Contact Lens and Anterior Eye
Citation Excerpt :
Using the same short questionnaire employed in this study, previous studies have reported dry eye rates based on clinical diagnosis and/or severe symptoms, with a DED prevalence ranging from 6.8 % to 24.4 % for previous diagnoses and 1.3 % to 10.4 % for severe symptoms, with studies in Asian countries showing high rates. Despite the wide range of published DED data, the DED prevalence in the current study exceeds that reported by previous epidemiological studies from various countries [34–37], with a number of studies restricted to specific towns [13,14,17,35,36]. This high rate could be attributed to the dry weather, low annual rainfall, low humidity, widespread use of air conditioners, ethnicity variations, high temperature, and sunlight, all of which can affect tear film quality and the ocular surface, leading to the disease [30,31,37,38].
To estimate the prevalence and associated risk factors of dry eye disease (DED) among the citizens of Saudi Arabia.
A cross-sectional prevalence survey was administered to 4066 healthy adults from the five main regions of Saudi Arabia. Initial estimates of the prevalence and associated risk factors of DED were calculated for the general population and then stratified by demographic characteristics such as age, sex, and location. DED was assessed by a short, validated dry-eye questionnaire.
The overall prevalence of DED was 49.5 % (n = 2016), including 33.1 % (n = 1347) of participants who reported a previous DED diagnosis and 16.4 % (n = 669) who reported severe symptoms; 14.7 % reported severe symptoms and a previous DED diagnosis (n = 598). The DED prevalence among men was 49.8 % (n = 1005) compared with 50.2 % (n = 1011) for women. The multivariate model analysis confirmed the increased prevalence of DED in women (OR 1.48; 95 % CI 1.30–1.88), those ≥60 years of age (OR 1.99; 95 % CI 1.60–2.81), those who had undergone refractive surgery (OR 1.79; 95 % CI 1.50–2.59), those having undergone acne treatment (OR 1.51; 95 % CI 1.34–1.97), contact lens wearers (OR 1.77; 95 % CI 1.40–2.48), those having taken antiallergy drugs (OR 2.23; 95 % CI 1.55–2.78) or antidepressants (OR 1.60; 95 % CI 1.14–2.44), and those who reported computer use of >6 h per day (OR 1.66; 95 % CI 1.41–2.52).
Dry eye is a common disease among the Saudi Arabian population. Prevalence is found to be high and vary significantly across the country. DED could be attributed to dry weather, low annual rainfall, low humidity, widespread use of air conditioners, air pollution, high temperature, and exposure to sunlight.

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Victor L. Perez, MD, performed his residency training at the Massachusetts Eye & Ear Infirmary (MEEI) in Boston, Massachusetts. He then completed a Cornea and External Diseases and Uveitis Fellowship at MEEI and a Research Fellowship for Ocular Immunology at Schepens Eye Research Institute. Dr Perez is currently the director of the Ocular Surface and Inflammation Research Program at Bascom Palmer Eye Institute. His clinical practice is dedicated to cornea and stem cell transplantation, medical and surgical care of patients with autoimmune disorders of the anterior segment and keratoprothesis.

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Original articlePrevalence and Risk Factors of Dry Eye Syndrome in a United States Veterans Affairs Population

Purpose

Design

Methods

Results

Conclusions

Section snippets

Study Population

DES Prevalence

Risk Factor Analysis of Demographic Characteristics

Discussion

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Value Health

Am J Ophthalmol

Clin Ther

Am J Ophthalmol

The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007)

Ocul Surf

Epidemiology of dry eye syndrome

Adv Exp Med Biol

Characterization of ocular surface symptoms from optometric practices in North America

Cornea

Prevalence of and risk factors for dry eye syndrome

Arch Ophthalmol

Self-reported assessment of dry eye in a population-based setting

Invest Ophthalmol Vis Sci

Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study

Arch Ophthalmol

Prevalence and associations of dry eye syndrome in an older population: the Blue Mountains Eye Study

Clin Experiment Ophthalmol

Prevalence of dry eye in Japanese eye centers

Graefes Arch Clin Exp Ophthalmol

Original article
Prevalence and Risk Factors of Dry Eye Syndrome in a United States Veterans Affairs Population