Abstract
Objectives:
Dry eye is a common condition that can decrease quality of life. This survey-based study of persons with dry eye investigated self-reported treatments (initial, current), out-of-pocket expenses, time spent on self-management, sources of care, and sources of information about their condition.
Methods:
Online dry eye newsletters and support groups were emailed a link to an electronic survey asking members to participate. Survey respondents were not required to answer every question.
Results:
In total, 639 persons with self-reported dry eye responded (86% women, 14% men [n=623]; mean±SD age, 55±14 years [n=595]). Artificial tears were the most reported intervention (76% initially, 71% currently). The median (IQR) out-of-pocket treatment cost annually was $500 ($200-$1,320 [n=506]). Additionally, 55% (n=544) estimated 5 to 20 minutes daily on self-management; 22% spent an hour or more. Ophthalmologists provided most dry eye care (67%, n=520). Only 48% (n=524) reported that their primary source of dry eye information came from their eye care clinician.
Conclusions:
Artificial tears are the primary treatment for dry eye. Ophthalmologists provide most dry eye care, but half of patients report their eye care provider is not their primary source of information. Almost one-fourth of patients spend an hour or more daily on treatments.
Keywords: burden of care, dry eye, dry eye treatment, patient experience
Dry eye disease is a chronic condition with a multifactorial cause, including physiologic changes in structures involved with maintaining the tear film (lacrimal insufficiency, meibomian gland dysfunction, goblet cell deficiency) as well as changes to ocular surface integrity.1 The diversity of causative factors for patients’ symptoms, along with possible discordance between symptoms and clinical signs, can make it challenging for patients and clinicians to provide the most effective therapy.
Dry eye disease may impart financial and temporal burdens of care for patients.2 Without quantifying these aspects of care, ascertaining treatment successes and deficiencies from the patient’s perspective is challenging. Our aim was to obtain information about the patient’s experience with treatment modalities, ocular symptoms, and burden of care associated with dry eye disease. Such knowledge may help lead to improved treatment algorithms.
Methods
This survey-based study was reviewed and deemed exempt by the institutional review board of the University of Illinois Chicago, Chicago, Illinois, which housed the REDCap (Research Electronic Data Capture) survey3,4 used in this study. The survey was developed by the SCOPE (Scleral Lenses in Current Ophthalmic Practice Evaluation) group. The survey was intended to be widely inclusive of symptoms and treatment for dry eye, without including so many questions as to make the questionnaire difficult to complete. The questionnaire was not designed as a standard dry eye evaluation survey but rather as a vehicle to elucidate patient experience with dry eye. The survey was designed to collect patient experiences and does not include ocular surface evaluation. All relevant data supporting the findings from this study are reported within the article and the supplemental materials. Data reported for this study are limited to the burden of dry eye care and primary sources of treatment and information.
A link to the survey (Supplement) was emailed by the Dry Eye Foundation and was also shared by administrators of support groups and foundations for persons with conditions associated with dry eye disease, including Sjögren syndrome, Stevens-Johnson syndrome, dysautonomia, and corneal neuralgia. Study team members identified themselves as researchers and clearly stated the study objectives when contacting social media group administrators for permission to distribute the survey to group members. The survey was active from March through October 2018. Survey respondents had a chance to win a $100 gift card. Only respondents who indicated that they had been diagnosed with dry eye disease were included.
Data Collection
Demographic data collected included age, sex, and the year during which respondents were first diagnosed with dry eye. Additional data collected included treatment modalities recommended at diagnosis, current therapeutic interventions used, out-of-pocket costs for therapy and professional fees, the amount of time spent each day to self-manage the disease, professional credentials of respondents’ primary clinician managing their dry eye, and the respondents’ principal sources of information about dry eye disease. Respondents were not required to answer every item.
To identify changes in dry eye management and burden of care over time, we divided participants into groups according to length of time since they first noticed dry eye issues. These disease-duration groups were very long-term (≥11 years), long-term (6-10 years), recent (>1-5 years), and very recent (≤1 year) dry eye.
Statistical Analysis
Initial and current treatments for each group of respondents were compared with a Pearson χ2 analysis. Data for the number of treatments and the estimated financial and time resources expended were tested for normality with the Anderson-Darling test. Median (IQR) differences are reported with additional nonparametric analyses due to nonnormal data distribution. The number of treatments at both treatment times (initial and current) was compared with the Mann-Whitney test. Financial expenditure and time spent daily on disease self-management were each compared with a Kruskal-Wallis test. P<.05 was considered significant. Comparative data are provided for sources of treatment and methods of obtaining information about dry eye.
Results
In total, 639 adult respondents with self-reported dry eye completed the survey. When fewer than 639 respondents answered a question, the number of responses is stated in the Results section. Most respondents were from the US (526/625, 84%), and 22 participants were from Canada and the United Kingdom; 35 additional countries were represented. Women represented 86% (533) of the 623 respondents who identified their sex. The mean±SD age was 54±14 years (range, 18-89 years; n=595; Table 1).
Table 1.
Demographic Characteristics of Survey Participants (N=639)a
| All respondents | Duration of dry eye disease |
||||
|---|---|---|---|---|---|
| Very long-term (≥11 y) | Long-term (6-10 y) | Recent (>1-5 y) | Very recent (≤1 y) | ||
| Age, y | (n=595) | (n=223) | (n=129) | (n=195) | (n=59) |
| Mean±SD | 54±14 | 57±13 | 53±14 | 52±15 | 50±15 |
| Range | 18-89 | 18-84 | 18-89 | 18-80 | 18-78 |
| Sex | (n=623) | (n=224) | (n=141) | (n=191) | (n=58) |
| Men | 90 | 19 | 21 | 34 | 15 |
| Women | 533 | 205 | 120 | 157 | 43 |
| Duration of dry eye, y | (n=627) | (n=226) | (n=144) | (n=195) | (n=59) |
| Mean±SD | 10.6±10 | 21.1±9.4 | 8.0±1.4 | 3.3±1.1 | 0.7±0.4 |
| Range | 0-63 | 11-63 | 6-10 | 2-5 | 0-1 |
Because participants were not required to answer every survey question, the number of “all respondents” differs by survey item and does not match the total number of participants who answered the question about duration of their dry eye disease.
Initial and Current Treatment
At the time of initial diagnosis for all 639 participants, 3 was the median number (IQR) of different dry eye treatments reported (1-5; range, 0-15); that number remained 3 for current treatments (1-5; range, 0-14; P=.60). No significant differences in the number of initial or current treatments were noted between disease-duration groups.
For all respondents, the most common treatment reported both initially and currently was artificial tears (76% [485/639] and 71% [456/639], respectively). However, no significant difference was observed in the percentage using artificial tears between the 2 treatment periods (P=.05) or when respondents were compared by their duration of dry eye disease (Table 2). Other treatments reported somewhat often for both initial and current therapy included warm compresses (39% [249/639] and 41% [259/639]), artificial tear gels (29% [187/639] and 27% [171/639]), and artificial tear ointments (29% [182/639] and 25% [157/639]). Treatment with lubricating ophthalmic ointments was reported as decreasing from 39% (90/229) initially to 28% (64/229) currently for participants with very long-term dry eye disease (P=.01).
Table 2.
Number of Reported Initial and Current Treatments by Duration of Dry Eye Diseasea
| All respondents (N=639) |
Very long-term (≥11 y) (n=229) |
Long-term (6-10 y) (n=144) |
Recent (>1-5 y) (n=195) |
Very recent (≤1 y) (n=59) |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial | Current | P valueb | Initial | Current | P valueb | Initial | Current | P valueb | Initial | Current | P valueb | Initial | Current | P valueb | |
| No. of treatments | |||||||||||||||
| Median (IQR) | 3 (1-5) | 3 (1-5) | .60 | 3 (1-5) | 3 (1-5) | .70 | 3 (1-5) | 3 (1-5) | .75 | 2 (1-4) | 3 (1-4) | .89 | 3 (1-4) | 2 (1-4) | .40 |
| Range | 0-15 | 0-14 | 0-15 | 0-14 | 0-10 | 0-13 | 0-15 | 0-9 | 0-7 | 0-9 | |||||
| Type of treatment, % of respondents | |||||||||||||||
| Artificial tears | 485 (76) | 456 (71) | .05 | 181 (79) | 173 (75) | .37 | 106 (74) | 96 (67) | .20 | 148 (76) | 138 (71) | .25 | 42 (71) | 41 (70) | .84 |
| Warm compress | 249 (39) | 259 (41) | .62 | 93 (41) | 99 (43) | .57 | 56 (39) | 59 (41) | .72 | 79 (41) | 77 (39) | .84 | 17 (29) | 19 (32) | .69 |
| Artificial tear gel | 187 (29) | 171 (27) | .29 | 76 (33) | 58 (25) | .06 | 39 (27) | 41 (29) | .79 | 50 (26) | 53 (27) | .73 | 19 (32) | 15 (25) | .42 |
| Artificial tear ointment | 182 (29) | 157 (25) | .10 | 90 (39) | 64 (28) | .01 | 40 (28) | 39 (27) | .90 | 39 (20) | 41 (21) | .80 | 11 (19) | 9 (15) | .62 |
| Cyclosporine (0.05%) eye drops | 164 (26) | 127 (20) | .01 | 61 (27) | 50 (22) | .23 | 44 (31) | 29 (20) | .04 | 44 (23) | 33 (17) | .16 | 14 (24) | 13 (22) | .83 |
| Punctal plug or cautery | 163 (26) | 147 (23) | .28 | 79 (35) | 68 (30) | .27 | 37 (26) | 35 (24) | .79 | 35 (18) | 35 (18) | 1.0 | 8 (14) | 7 (12) | .78 |
| Corticosteroid eye drops | 136 (21) | 83 (13) | <.001 | 42 (18) | 26 (11) | .04 | 32 (22) | 23 (16) | .18 | 41 (21) | 25 (13) | .03 | 18 (30) | 8 (14) | .03 |
| Eyelid cleansers | 93 (15) | 145 (23) | <.001 | 36 (16) | 57 (25) | .02 | 24 (17) | 38 (26) | .05 | 25 (13) | 40 (21) | .04 | 6 (10) | 7 (12) | .77 |
| Contact lenses | 47 (7) | 94 (15) | <.001 | 19 (8) | 36 (16) | .02 | 11 (8) | 20 (14) | .09 | 12 (6) | 27 (14) | .01 | 3 (5) | 9 (15) | .07 |
| Oral medication to increase tear production | 45 (7) | 54 (8) | .36 | 23 (10) | 21 (9) | .75 | 10 (7) | 13 (9) | .51 | 11 (6) | 19 (10) | .13 | 0 (0) | 0 (0) | NA |
| Allergy eye drops | 44 (7) | 38 (6) | .48 | 18 (8) | 19 (8) | .86 | 12 (8) | 8 (6) | .35 | 10 (5) | 10 (5) | 1.0 | 3 (5) | 0 (0) | .08 |
| Antibiotic eye drops | 42 (7) | 23 (4) | .02 | 13 (6) | 10 (4) | .52 | 9 (6) | 4 (3) | .16 | 10 (5) | 5 (3) | .19 | 7 (12) | 3 (5) | .19 |
| Moisture chamber glasses or goggles | 36 (6) | 73 (11) | <.001 | 26 (11) | 36 (16) | .17 | 2 (1) | 14 (10) | .002 | 5 (3) | 16 (8) | .01 | 1 (2) | 4 (7) | .17 |
| Oral antibiotic | 33 (5) | 25 (4) | .27 | 12 (5) | 8 (4) | .36 | 9 (6) | 8 (6) | .80 | 8 (4) | 6 (3) | .59 | 4 (7) | 2 (3) | .40 |
| Autologous serum tears | 27 (4) | 47 (7) | .02 | 12 (5) | 20 (9) | .14 | 4 (3) | 13 (9) | .02 | 8 (4) | 9 (5) | .80 | 3 (5) | 4 (7) | .70 |
| Lifitegrast | 21 (3) | 44 (7) | .007 | 3 (1) | 20 (9) | <.001 | 2 (1) | 12 (8) | .006 | 14 (7) | 9 (5) | .31 | 1 (2) | 1 (2) | 1.0 |
| NSAID eye drop | 17 (3) | 14 (2) | .58 | 4 (2) | 4 (2) | 1.0 | 7 (5) | 4 (3) | .36 | 5 (3) | 4 (2) | .74 | 1 (2) | 2 (3) | .56 |
| Meibomian gland expression | 15 (2) | 23 (4) | .19 | 7 (3) | 8 (4) | .79 | 1 (1) | 7 (5) | .03 | 7 (4) | 6 (3) | .78 | 0 (0) | 1 (2) | 1.0 |
| Amniotic fluid drops | 4 (<1) | 5 (<1) | .74 | 3 (1) | 2 (1) | .65 | 1 (1) | 1 (1) | 1.0 | 0 (0) | 1 (<1) | 1.0 | 0 (0) | 1 (2) | 1.0 |
| Nasal tear stimulator | 0 (0) | 0 (0) | NA | 0 (0) | 0 (0) | NA | 0 (0) | 0 (0) | NA | 0 (0) | 0 (0) | NA | 0 (0) | 0 (0) | NA |
Abbreviations: NA, not applicable; NSAID, nonsteroidal anti-inflammatory drug.
Because participants were not required to answer every survey question, the number of “all respondents” does not match the total number of participants who answered the question about duration of their dry eye disease.
Mann-Whitney test.
Less commonly reported initial treatments included 0.05% cyclosporine eye drops, punctal plugs or punctal cautery, and corticosteroid drops (Table 2). Reported cyclosporine use decreased from 26% (164/639) as initial therapy to 20% (127/639) of current therapy (P=.01) for all respondents. Participants reported that corticosteroid drops were more often used as initial treatment (21%, 136/639) than as current treatment (13%, 83/639) (P<.001). However, eyelid hygiene, contact lenses, and moisture chamber goggles or glasses were more commonly reported as current treatments (23% [145/639], 15% [94/639], and 11% [73/639], respectively) than initial treatments (15% [93/639], 7% [47/639], and 6% [36/639]) (all P<.001).
Less than 8% of respondents reported using oral medication to increase tear production (eg, pilocarpine tablets), allergy eye drops, antibiotic eye drops, oral antibiotics, lifitegrast, or autologous serum as either initial or current therapy (Table 2). Lifitegrast and autologous serum drops were more frequently reported with current treatments (7% each) than with initial treatments (lifitegrast, 3%; P=.007; autologous serum drops, 4%; P=.02).
Less than 4% of all participants reported that initial or current treatments included topical nonsteroidal anti-inflammatory drugs, meibomian gland expression, or amniotic fluid drops. No participants reported initial or current use of nasal-based neurostimulation.
Financial and Temporal Effects of Dry Eye Disease Management
Overall, the median (IQR) estimated annual out-of-pocket cost was $500 ($200-$1,320; n=506). Estimated out-of-pocket treatment costs varied widely from $0 to $65,000 per year. Despite this range, the median costs were not significantly different between disease-duration groups (P=.78).
Responses varied widely regarding the amount of time each day spent on dry eye self-management (n=544; Figure). Approximately 33% of respondents (182/544) reported they spent between 0 and 10 minutes on dry eye self-management, and another 25% of respondents (135/544) reported spending 15 to 20 minutes per day managing their disease. Twenty-two percent (119/544) reported spending an hour or more per day on dry eye self-management. The median (IQR) time spent for all groups was 20 minutes (10.0-37.5 minutes), with no significant difference between time categories (P=.86).
Figure.
Reported Time Spent Daily on Dry Eye Management (n=544).
Sources of Care and Information
Most participants in this study (68%, 351/520) reported obtaining their dry eye care from ophthalmologists; this finding was consistent across all disease-duration groups (Table 3). About one-fourth of the participants (26%, 135/520) reported that they obtained their dry eye care from an optometrist, and 7% (34/520) reported receiving dry eye care elsewhere.
Table 3.
Reported Primary Dry Eye Care Clinician and Primary Source of Dry Eye Information by Disease-Duration Groupa
| All respondents | Very long-term (≥11 y) | Long-term (6-10 y) | Recent (>1-5 y) | Very recent (≤1 y) | |
|---|---|---|---|---|---|
| Source of dry eye care, % | (n=520) | (n=190) | (n=119) | (n=158) | (n=46) |
| Ophthalmologist | 351 (68) | 122 (64) | 80 (67) | 113 (72) | 30 (65) |
| Optometrist | 135 (26) | 59 (31) | 28 (24) | 39 (25) | 8 (17) |
| Other | 34 (7) | 9 (5) | 11 (9) | 6 (4) | 8 (17) |
| Source of dry eye information, % | (n=524) | (n=193) | (n=117) | (n=160) | (n=45) |
| Eye care clinician | 251 (48) | 83 (43) | 58 (50) | 82 (51) | 23 (51) |
| Internet search | 153 (29) | 64 (33) | 28 (24) | 47 (29) | 11 (24) |
| Online support group | 101 (19) | 39 (20) | 27 (23) | 25 (16) | 10 (22) |
| Other | 19 (4) | 7 (4) | 4 (3) | 6 (4) | 1 (2) |
Because participants were not required to answer every survey question, the number of “all respondents” differs by survey item and does not match the total number of participants who answered the question about duration of their dry eye disease.
Only 48% of 524 respondents (n=251) reported that their primary source of information about dry eye disease was obtained from their eye care clinician (Table 3). Another 29% (153/524) reported that searching the internet was their primary source of dry eye–related information, and 19% (101/524) reported getting their primary information from online support groups. The other 4% of respondents (19/524) reported other sources, including non–eye care clinicians (rheumatologist, immunologist), books, office pamphlets, and family members.
Discussion
This survey of persons with different durations of dry eye disease provided insight into living with the condition. In agreement with the known demographic characteristics of patients with dry eye,5 this cohort of persons with dry eye consisted predominantly of middle-aged women. Because early definitions of dry eye focused on aqueous deficiency,6 and aqueous replacement alone was advocated for many years, we were not surprised that artificial tears were the mainstay of therapy for survey participants—both those with recent diagnoses and those with long-term diagnoses of dry eye. These products are readily available, are relatively easy to use, and have a favorable safety profile.7 Artificial tears temporarily supplement aqueous volume but cannot mimic the complex chemistry of the precorneal tear film. As our understanding of dry eye disease has expanded to include the major role of meibomian gland dysfunction on tear quality,1,8,9 artificial tears formulated to support the lipid layer have been introduced and may be more effective for some patients.10,11 The finding that artificial tears remain in use by 75% of our survey respondents with very long-term dry eye disease implies that they provide some level of dry eye relief without adding an unreasonable burden of care.
Evidence that clinical recommendations for managing dry eye lag evidence-based recommendations8,12 was furthered by the survey finding that treatments aimed at evaporative dry eye were underused. Treatment of meibomian glands with proper eyelid hygiene and in-office meibomian gland expression can improve the signs and symptoms of dry eye while promoting restored meibomian gland health.13 In our survey population, initial and current use of warm compresses was reported by less than 50%, use of eyelid hygiene was reported by less than 25%, and use of meibomian gland expression was reported by less than 4%. Respondents were more likely to report that eyelid hygiene was part of their current treatments than their initial therapy. Alghamdi et al,14 however, reported that only 55% of patients (104/188) for whom eyelid hygiene was recommended maintained the intervention 6 weeks later. Of the 84 patients in their study who discontinued treatment, 56% (47/84) believed they did not need therapy, 33% (28/84) reported that they forgot treatment, and 11% (9/84) reported that treatment was inconvenient.14 Warm compresses and eyelid hygiene require more time than instilling an eye drop, and results are not as immediately rewarding; therefore, therapy that focuses on managing eyelid contributions to dry eye disease may seem overly burdensome to some patients. Whether these treatments were recommended but not adopted by our survey respondents was not queried, but of importance, the patients reported they did not use basic, commonsense therapies that are known to improve symptoms. Barriers to access for in-office advanced meibomian gland therapies may include equipment cost, the substantial operational infrastructures required to provide such services, and lack of insurance coverage.
Prescription eye drops are as simple to use as artificial tears and provide additional therapeutic benefits. For a time, definitions of dry eye were focused on an inflammatory component.15 Corticosteroids and eventually longer-term anti-inflammatory agents with better safety profiles such as cyclosporine and lifitegrast became popular therapies for dry eye. Corticosteroid drops are typically recommended for amelioration of acute, inflammatory exacerbations of dry eye16,17 but are associated with increased risk of ocular disease (cataract, elevated intraocular pressure, increased infection risk). In our study, corticosteroids were recommended more frequently for initial use than current use. This finding supports the use of steroids to reduce acute inflammation, while avoiding long-term use to minimize the risk of complications.
Approximately 25% of respondents reported initial treatment with 0.05% cyclosporine eye drops, and 20% reported current use of this medication. Participants categorized in the long-term (6-10 years) dry eye group reported the highest initial use of 0.05% cyclosporine (31%), yet only 20% of that same group reported continued use. Among the very recently diagnosed respondents, 24% reported initial use and 22% reported current use of 0.05% cyclosporine. Our results indicate decreased use with time, whereas higher rates of cyclosporine use would be expected as a function of longer disease duration. Instead, the very recent and very long-term disease-duration groups used cyclosporine equally for current therapy. Reasons reported by other investigators for patients’ discontinuing cyclosporine treatment include cost, lack of insurance coverage, no improvement of symptoms, and discomfort with use.18 Lifitegrast, which is fairly new to the market, was used by only 7% of respondents in the study population. Given the most recent treatment recommendations for dry eye from the Tear Film and Ocular Surface Society,12 longer-term anti-inflammatory agents are certainly useful to mitigate ocular surface inflammation but most likely do not work in isolation and should be combined with other therapies that address eyelid disease, corneal nerve abnormalities, and lifestyle decisions.
Certain dry eye treatment options were rarely used. Medical contact lenses were used infrequently as initial dry eye management, but their use more than doubled over time (from 7% initially to 15% currently). Scleral lenses are increasingly being used to manage dry eye disease after more conservative topical therapies fail.19–21 However, the burden of care for contact lenses is relatively high compared with other therapeutic options for dry eye; in our experience, the cost, initial fitting, training in application and removal, and ongoing visits to ensure proper fit and lens care can be deterrents to lens use. Moisture chamber glasses or goggles also were more frequently introduced after the initial dry eye evaluation. These devices protect the eye from desiccating stress, relieve symptoms, and are simple to use and inexpensive, but poor cosmesis may make some persons with dry eye hesitant to avail themselves of this option. Autologous serum tears were used by fewer than 10% of respondents and were generally not introduced as initial therapy in this study population. Although serum tears may be effective, they require blood draws and proper storage of serum vials, and they are not covered by insurance. Oral antibiotics, topical antibiotics, and allergy drops were used less than 8% of the time, with minimal change from initial to current use. Like topical corticosteroids, these treatments may be used for limited periods to address acute exacerbations (eg, for seasonal allergies or in dry environments).
A noteworthy finding was that most respondents used 3 therapeutic options on average regardless of time since their diagnosis. The consistent use of multiple therapeutic options suggests that monotherapy may not provide adequate symptomatic relief, even in newly diagnosed dry eye disease. When the burden of care, costs of multimodal therapy, or both become unacceptable, patient compliance tends to wane. Decreased adherence with multiple antiglaucoma medications is well documented.22–24 Management of dry eye disease is clearly a time burden for patients. Although more than half of respondents reported spending 20 minutes or less a day for dry eye self-management, 22% reported that their therapy required an hour or more daily. Not only is an hour a considerable amount of time, but this time is frequently distributed throughout the day, requiring patients to disrupt their activities to deal with their chronic disease. This may result in reduced work productivity and quality of life. Eye care clinicians should thoughtfully prescribe therapeutic regimens that will address the primary cause and secondary effects of disease while minimizing the burden of interventions.
In addition, managing dry eye disease may create an economic burden for patients. The estimated mean annual cost of disease management was $1,578 for all respondents regardless of disease duration. When only US participants were analyzed from the current study, the average yearly out-of-pocket cost of dry eye treatment was $1,294 per year. This cost is a 65% increase from that in 2008, when the estimated annual average cost of dry eye therapy was $783,2 an increase that outpaced inflation during this time, according to the US Consumer Price Index.25 This increase could reflect the availability of new therapies that are not covered by insurance. As out-of-pocket costs increase, patients on fixed incomes and those with limited insurance coverage may forego recommended treatments. Inadequate treatment of dry eye disease will result in progression. Although this study design did not allow for evaluation of disease severity, the study by Yu et al2 reported an increase in treatment costs as disease severity increased.
Most survey respondents reported receiving care for their dry eye disease from an eye care professional, usually an ophthalmologist (67%) and less often an optometrist (26%). This finding is consistent with a literature review by Reddy et al,26 in which ophthalmologists were reported to provide most dry eye care. Although eye care clinicians are probably more likely than other clinicians to be aware of the latest evidence-based diagnostic tests and therapeutic interventions for dry eye, 7% of respondents reported receiving most of their dry eye care from non–eye care specialists. Also concerning was that only 48% of respondents identified an eye care clinician as the primary source of information about dry eye disease. Instead, nearly half of respondents used internet searches (29%) or online support groups (19%) as their primary sources of current information about their condition. Although reputable sources of information exist (eg, foundations dedicated to a particular disease, selected dry eye disease–focused websites), misinformation that may directly contradict evidence-based recommendations may also be encountered in this unregulated environment. Eye care clinicians would be well advised to ensure that their patients with dry eye thoroughly understand the pathophysiologic characteristics of their disease and all appropriate treatment options. Clinicians should also direct patients to reputable resources for further information. Lines of communication must be available, and follow-up visits should be arranged to ensure that adequate symptomatic relief is maintained. Patients who perceive their disease is well controlled and who have been fully educated about their condition may be less likely to seek out alternative sources of information that may not be reputable.
Limitations
Limitations of this study include those common to all survey-based research, such as the potential for selection bias and recall bias. The study is also limited only to the opinions of those who responded. It was not possible to know the demographic or treatment information of nonresponders to this study; therefore, the representative nature of this sample cannot be known. Online administration of this survey may have biased the sample toward respondents who were more likely than others to use online sources of knowledge regarding dry eye. In addition to these limitations, this survey did not attempt to evaluate clinical disease severity or to quantify improvements in symptoms with various interventions. The advantage of an in-person examination would have allowed for correlating signs and symptoms, along with response to treatment. The study results are limited by lack of a clinical examination, so improvement from or failure of a treatment could not be evaluated in respondents or nonrespondents. Dry eye treatment may have been selected based on clinical signs that were not evaluated in this study. Survey respondents were not queried as to why particular treatments were initiated or discontinued. Respondents were not asked to distinguish between whether they self-initiated or self-discontinued a therapy without input from their clinician. Specific information about branded products used was not explored, nor was the frequency of use of some newer therapeutic options. Additional studies could be conducted to address these limitations.
Conclusion
This study provided information regarding aspects of dry eye care that are not normally explored during patients’ office visits, such as the time required for disease management, financial cost of treatment, and patients’ preferred sources of information. Our findings may help to raise awareness among eye care clinicians of the burden of dry eye disease for patients.
Supplementary Material
Acknowledgment
The Scientific Publications staff, Mayo Clinic, provided editing, proofreading, administrative, and clerical support.
Conflicts of Interest and Source of Funding
A. Nau has consulted for Oyster Point Pharma and has been a paid lecturer for Eye Eco.
J. Harthan is a consultant for Allergan, Essilor of America, Euclid Systems Corp, International Keratoconus Academy, Metro Optics, Visioneering Technologies Inc, Bausch + Lomb Inc, Kala Pharmaceuticals, and Ocular Therapeutix Inc.
J. Fogt has received research funding from Nevakar Inc, EyeNovia Inc, Alcon, Innovega Inc, and Contamac US Inc and consulted for Alcon and Contamac.
E. Shorter has received a research grant from Johnson & Johnson, SynergEyes, and Art Optical Contact Lens Inc and was a paid speaker for BostonSight and Oculus.
The other authors have declared no potential conflicts of interest.
This project was supported by Grant Number UL1 TR002003 from the National Center for Advancing Translational Sciences (NCATS) (to University of Illinois Chicago [UIC]) and by NIH Grant P30 EY001792 (core grant to UIC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
This work also was funded by an unrestricted departmental grant from Research to Prevent Blindness to the Department of Ophthalmology and Visual Sciences, UIC. The funding sources had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Footnotes
Presented as an abstract at the American Academy of Optometry (AAOPT) 98th Annual Meeting; October 23-26, 2019; Orlando, Florida.
Contributor Information
Cherie B. Nau, Department of Ophthalmology (C Nau and Schornack), Mayo Clinic, Rochester, Minnesota.
Amy C. Nau, Korb & Associates (A Nau), Boston, Massachusetts.
Jennifer S. Fogt, The Ohio State University (Fogt), Columbus, Ohio.
Jennifer S. Harthan, Illinois College of Optometry (Harthan), Chicago, Illinois.
Ellen S. Shorter, Department of Ophthalmology and Visual Sciences (Shorter), University of Illinois Chicago, Chicago, Illinois.
Muriel M. Schornack, Department of Ophthalmology (C Nau and Schornack), Mayo Clinic, Rochester, Minnesota.
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