Study: Dry eye may not worsen over time

Dry eye disease (DED) has long been thought to be a progressive condition, but a study published in Ophthalmology found that most of its participants who were diagnosed with DED reported no change or some level of improvement.

For the study, researchers used a combination of self-reported patient information and review of medical records to assess the natural history of DED among a group of men and women with an average duration of DED of 10.5 and 14.5 years, respectively. The majority of participants recalled little or no change in ocular surface symptoms, vision-related symptoms, or the social impact of DED since diagnosis, and a similar number described an improvement as reported worsening. 

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But the study raised more questions than it answered for many dry-eye experts.

“Does DED progress, and how quickly? This study doesn’t clarify it for me,” says Optometry Times blogger Leslie O’Dell, OD, FAAO. “It does however demonstrate the need to further study this idea using repeatable clinical data in addition to patient symptoms. It also pushes me to be more consistent in my own charting for patients using Dry Eye Workshop (DEWS) criteria and utilizing the same testing from one visit to the next in order to determine when treatments are effective and if disease is progressing despite my efforts.”

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Next: The study details-and limitations

The study details-and limitations

Researchers recruited study participants from two large longitudinal studies of healthcare professionals in the U.S.-the Women’s Health Study and the Physicians’ Health Studies I and II-in which diagnoses of dry eye disease or its symptoms were assessed using a short questionnaire. From those cohorts, researchers selected 4,000 participants (2,500 women and 1,500 men) who previously reported a diagnosis of dry eye disease or severe dry eye symptoms.

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Researchers then assessed the study participants using the Ocular Surface Disease Index (OSDI) and Symptom Assessment in Dry Eye questionnaires and looked at factors like comorbid conditions, dry eye treatments, cost of dry eye treatments, other medication use, patient satisfaction with dry eye treatments, and the impact of dry eye on quality of life. Researchers classified participants according to the schema of the International Dry Eye Workshop.

One year later, researchers conducted a second questionnaire to a subgroup of 1,000 participants who had reconfirmed a diagnosis of dry eye disease. The questionnaire was administered to assess patient-reported data changes in dry eye disease relative to when it was first diagnosed. Participants were asked to rate how they feel now compared to how they felt when they were first diagnosed. Researchers also assessed participants’ medical records.

Each of the dry eye experts who commented noted that the study had some limitations, and thus may not be telling the whole story.

Whitney Hauser, OD, of The Eye Center at the Southern College of Optometry, says that quantifying subjective symptoms is difficult even with validated surveys and good study design.

“Two of the limitations identified in the study were the fact that patients may have learned to cope with the disease and the exacerbating and remitting nature of the conditions,” says Dr. Hauser. “Both play a critical role in the patient’s appreciation of a progressive deterioration.

She also says that some patients report that dry eye disease has devastated their lives for years, and there is no room for further decline in their minds. That patient perception is one that raised red flags for all of the dry eye experts.

“This large scale study makes some interesting points,” says Optometry Times blogger Scott Schachter, OD, “but has some limitations, including patient recollection of symptoms over a 10- to 15-year time frame.”

Another problem was the average age of the participants-65 years old for men, and 56 years old for women.

“Could they have already progressed in earlier years, and this was not seen?” says Dr. O’Dell.

Next: What the results mean for you

What the results mean for you

Should the findings of this study affect the way you manage your dry eye patients?

“If we relied on the premise that dry eye disease is progressive in the strictest sense,” says Dr. Hauser “many of our patients whose symptoms began in mid-life would likely be debilitated by the end of their lives. The vast majority are not.”

Importantly, the study found that patients with corneal staining, severe symptoms, or those who were being treated with beta blockers appear to be most at risk for progression and should be treated aggressively as soon as possible.

“What these findings suggest to me is that DED may be slowly progressive with a symptomatic tipping point that once met, escalates over time,” says Optometry Times Editorial Advisory Board member Katherine Mastrota, MS, OD, FAAO. “Additionally, we must be vigilant on patients’ medication history and aggressively manage lid and meibomian gland disease in an effort to delay reaching that time where DED and ocular surface disease take their toll.”

Dr. Schachter says that in his own experience, early treatment results in better outcomes, and he will continue to do so in his own practice while also looking closer at patients taking beta blockers.

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Dr. O’Dell says the study drives home the need for continued growth in diagnostic testing while also highlighting the underutilization of the tests currently available.

“How can outcomes be properly evaluated without consistent clinical data from one patient encounter to the next?” she says. “Outcome-based medicine is here, and we need to embrace it and work toward improved outcomes for our patients.”

Dr. Hauser agrees that patients’ perceptions of their symptoms over such an extended period of time may have played a part in the study’s outcome-but that patient perception may require closer attention. 

“Due to the complex, multifactorial nature of the disease and countless triggers (some of which we know and other we do not), subjective changes in a broad base doesn’t alter my clinical practice,” says Dr. Hauser. “It does heighten my awareness that doctors must be objectively vigilant because patient’s perceptions may not tell the full story.”

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