Abstract
BACKGROUND:
Dry eye (DE) can effect on quality of life by pain, inability to perform certain activities that require prolonged attention (driving, reading,…) and productivity at work and finally effect to Q0L associated with DE. OSDI is scale questionnaire is created team to measure the quality of life related to ocular surface disease.
AIM:
To describe the dry eye disease according to OSDI scale and related factors of this disease.
METHODS:
A cross-sectional descriptive study was carried out on outpatients (≥ 16-year-old) who were examined and diagnosed with dry eyes at Vietnam National Institute Of Ophthalmology from April to July 2018. Data was collected using the OSDI questionnaire.
RESULTS:
The average age of participants was 44.6 years; 80.9% of patients were female; 39.9% were identified having mild dry eye. The related factors have been identified that associated with severe dry eye, including age OR = 1.03 (95% CI: 1.01-1.05, p = 0.005), binocular good vision OR = 0.11 (95% CI: 0.05-0.23; p < 0.0001), medical history OR = 17.09 (95% CI: 2.24-130.25; p < 0.0001), chronic conjunctivitis OR = 0.36 (95% CI: 0.14-0.91; p = 0.027), refractive errors OR = 0.14 (95% CI: 0.04-0.48; p < 0.0001), Sjogren’s syndrome OR = 31.13 (95% CI: 7.08-136.76; p < 0.0001).
CONCLUSION:
Several related factors have been identified associated with severe dry eye, including: age, binocular good vision, medical history, chronic conjunctivitis, refractive errors, Sjogren’s syndrome.
Keywords: Dry eyes, Quality of life, OSDI, DES questionnaire
Introduction
Dry eye (DE) is an increasing public health issue which causes the discomfort and visual disturbance and which affects the quality of life, including physical, psychological and social aspects, daily activities and labor productivity.
“Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles” [1]. It is the most common ocular surface disease over the world with the prevalence from 4.4% to 50% in the older and middle-aged patients [2], [3]. In the US, it is estimated from the largest studies that dry eye can affect around 5 million people over 50 years old [4]. Many studies have shown that this disease “is a major cause of visual disturbance which can degrade the quality of daily life and affect health status” [5], [6]. On the other hand, the prevalence of DE is increasing due to the growing demands of modern life styles such as using computers, air conditioning and longevity in the last few years, which are considered as causes of dry eye. Many studies have shown that dry eye can effect on quality of life by pain, uneasy to perform certain activities that require prolonged attention (driving, reading, …) and reducing productivity at work. Currently, therefore, the main goal of treating dry eyes is to improve eye comfort and maintain the quality of life for patients [7]. This is the main motivation for both patients and society in general and raising awareness about dry eyes in society through educational activities
In recent years, there are many questionnaires used to assess the condition of patients with dry eyes. The tools to measure QoL help to prove scientifically about the impact of health on QoL. Some tools are widely used such as and SF-36 (Medical Outcomes Study Short Forms) and QOWBS (Quality of Well-Being Scale)… However, each of the different diseases has different characteristics, so that the questionnaire for measurement quality of life in different diseases is often developed by researchers with special tools. OSDI is the most commonly tool for frequency and severity assessment of DE in clinical. The scale consists of 12 questions divide into three categories: ocular symptoms, visual function disturbances, and environmental factors. The severity of symptoms on Likert scale is recorded on a 4-point from 1 to 4 points, the higher the score, the higher the Q0L effect. If the frequency scale is zero, the scale score is also 0. We believe the score represents the burden of patients and is more exact to evaluate the severity of the disease [7], [8], [9].
In the world, there have been many studies on the quality of life on people with dry eye disease in different aspects. However, there are very few studies about this issue in Vietnam until now. We think that this issue is very important because it provides information related to DE in the aspect of quality of life. It also provides reccommendations for ophthalmologists to pay more attention to the complaints in patients with dry eye and enables doctors to understand the patient’s needs and offer a better treatment. Therefore, we carried out this study.
Materials and methods
Patient
Subjects included 175 DE outpatients who were examined in Vietnam National Institute of Ophthalmology (VNIO) from April 2018 to July 2018.
Selection criteria: Participants included DE outpatients with the age from 16 to 72 of years. Criteria of dry eye diagnosing include: OSDI > 12 points; 2 out of 3 positive dry eye tests (BUT test ≤ 5 s, Schirmer test ≤ 5 mm, Fluorescein or Rose Bengal staning).
Exclusion criteria: Patients who do not agree to participate in the study or are unable to respond (mental patients, language problems).
Research design
A cross-sectional descriptive study was conducted. Data were collected by direct interview with patients using OSDI questionaires. OSDI (Ocular surface Disease Index) questionaire was used to evaluate and diagnose dry eye status. The questions in scale were grouped into 3 groups: ocular symptoms (Eyes that are sensitive to ligh, Eyes that feel gritty, Painful or sore eyes, Blurred vision, Poor vision), visual disturbance (reading, driving at night, working with a computer or banking machine (ATM), watching TV), and environmental factors (windy condition, Places or areas with low humidity (very dry), Areas that are air conditioned). OSDI score was calculated and classified into Normal: (0-12 points); Mild (13-22 points); Moderate (23-32 points); Severe (33-100 points) (Figure 1) [7].
Figure 1.
https://www.collinsoptometrists.com.au/wp-content/uploads/2016/01/OSDI-questionaire.pdf; Data entry and analysis using Epidata 3.0 and SPSS 16.0
Results
General information of research subjects
The study was conducted on 178 subjects and the average age of participants was 44.6 years, standard deviation was 14.65 years with a range between 16 and 72 years of age.
A number of demographic information was collected in our study including educational level, ethnic, occupation, geography and monthly average income. The majority of subjects have professional education of high school or lower (61.8%); 98.3% of subjects were Kinh people. The occupation of the subjects was distributed unevenly: the highest proportion in the farmer group (37.6%), followed by the office staff (25.3%); other occupations (19.7%), business (13.5%) and lowest proportion in worker group (3.9%). There was no stastically significant difference between geography groups. The majority of research subjects had monthly average income per capita less than 5 million VND (63.5%).
In our study, the majority of patients had good visual acuity with pinhole or glasses (50% of right eyes and 52.2% of left eyes), followed by morderate vision (25.8% of right eyes and 27.5% of left eyes) and low and blind vision (24.2% of right eyes and 20.3% of left eyes).
Characteristic of medical history
Among 178 of research subjects, 87.6% had at least one type of medical history Types of medical history included arthritis (30.3%), allergic diseases (25.8%), Sjogrens’s syndrome (20.5%), chronic conjunctivitis (17.4%), refractive errors (15.5%), hypertension (5.2%), diabetes (1.3%) and other autoimmune diseases (1.9%), (Table 2).
Table 2.
Medical history of patients (n = 178)
| Medical history | Number (n) | Proportion (%) | |
|---|---|---|---|
| Medical history | Yes | 156 | 87.6 |
| No | 22 | 12.4 | |
| Chronic conjunctivitis | Yes | 27 | 17.4 |
| No | 128 | 82.6 | |
| Refractive error | Yes | 24 | 15.5 |
| No | 131 | 84.5 | |
| Allergic diseases | Yes | 40 | 25.8 |
| No | 115 | 74.2 | |
| Diabetes | Yes | 2 | 1.3 |
| No | 152 | 98.7 | |
| Hypertension | Yes | 8 | 5.2 |
| No | 147 | 94.8 | |
| Sjogren’s syndrome | Yes | 32 | 20.6 |
| No | 123 | 79.4 | |
| Athritis | Yes | 47 | 30.3 |
| No | 108 | 69.7 | |
| Other autoimmune diseases | Yes | 3 | 1.9 |
| No | 152 | 98.1 | |
| Chronic conjunctivitis | Yes | 31 | 19.9 |
| No | 125 | 80.1 | |
Table 1.
Social – demographic information (n = 178)
| Characteristics | Number (n) | Proportion (%) | |
|---|---|---|---|
| Age | 16-39 | 62 | 38.4 |
| 40-59 | 78 | 43.7 | |
| ≥ 60 | 38 | 21.3 | |
| Sex | Male | 34 | 19.1 |
| Female | 144 | 80.9 | |
| Highest professional/ educational level | Secondary school | 14 | 7.9 |
| High school | 96 | 53.9 | |
| College | 28 | 15.7 | |
| University | 36 | 20.2 | |
| Postgraduate | 4 | 2.2 | |
| Ethnic | Kinh | 175 | 98.3 |
| Others | 3 | 1.7 | |
| Ocupation | Officer | 45 | 25.3 |
| Worker | 7 | 3.9 | |
| Farmer | 67 | 37.6 | |
| Business | 24 | 13.5 | |
| Others | 35 | 19.7 | |
| Geography | Rural | 89 | 50 |
| Mountain region | 01 | 0.6 | |
| Urban | 88 | 49.4 | |
| Monthly average income per capita | < 5 millions VND | 113 | 63.5 |
| ≥ 5 million VND | 65 | 36.5 | |
Description of quality of life related vision according OSDI
According to Figure 1, regarding to the discomfort of ocular surface symptom the majority of patients complained of light sensitivity (41.1%), gritty sensation (31.5%), eye pain (43.3%), blurred vision and poor vision (29.8%).
Figure 1.
Symptoms of discomfort of ocular surface
On the other hand, most of patients with the symptoms of blurred vision and poor vision experienced this condition all of the time (73.0%). The mean OSDI score of discomfort of ocular surface symptom group was 48.6 ± 26.15.
According to Figure 2, regarding to visual disturbance, among patients had discomfort feeling when reading and watching TV, these symptoms occurred occasionally with the rate of 36% and 29.8% respectively. The majority of participants were farmer, therefore most of them had no answer for the question “when working with a computer or bank machine (30.3%). In patients with discomfort when driving at night, the proportion of disturbance frequency level seemed to be equal. The mean OSDI score of visual disturbance symptom group was 43.64 ± 25.29.
Figure 2.
Symptoms of visual disturbance
Figure 3.
Symptoms of dry eyes related environmental condition
Most of participants answered that they felt uncomfortable at the frequency “half of time” in the windy conditions (31.5%) and areas that are air conditioned (29.2%). In the condition of low humidity (very dry), the prevalence of participants felt uncomfortable at the frequency “all of the time”, “most of the time” and “half of the time” was 30.3%, 28.7% and 27.5% respectively. The mean OSDI in the goup of activated symptoms due to environmental factors was 53.37 ± 28.81.
In our study, moderate dry eye accounted for the highest proportion in 3 groups (52.2%), followed by severe dry eye (39.9%) and the lowest was mild dry eye (7.9%), (Table 3).
Table 3.
Dry eye severity according OSDI scale
| Severity | Number (n) | Proportion (%) |
|---|---|---|
| Mild (13-22 points) | 14 | 7.9 |
| Morderate (23-32 points) | 93 | 52.2 |
| Severe (33 – 100 points) | 71 | 39.9 |
| Total | 178 | 100 |
The relationship between some social- demographic factors and severe dry eye
Age was one of related factors of dry eye (OR 1.03 (95%CI 1.01 – 1.05). The prevalence of dry eye in the group having higher educational level (above high school) was 58.8%, lower than that of the group having lower educations level (60.9%).
The highest prevalence of severe dry eye by occupation was in farmer group (46.7%), followed by the farmer group (38.8%) and the lowest in other occupations (36.4%), (Table 4).
Table 4.
The relationship between some social-demographic factors and severe DE
| Factors | Yes | No | OR 95%CI | P | |||
|---|---|---|---|---|---|---|---|
| n | % | n | % | ||||
| Age | 1.03 (1.01 – 1.05) | 0.005* | |||||
| Sex | Male | 12 | 35.3 | 22 | 64.7 | 1.27(0.59 – 2.77) | 0.543 |
| Female | 59 | 41 | 85 | 59 | |||
| Educational level higher than high school | Yes | 28 | 41.2 | 40 | 58.8 | 1.09 (0.59 – 2.02) | 0.782 |
| No | 43 | 39.1 | 67 | 60.9 | |||
| Occupation | Others | 24 | 36.4 | 42 | 63.6 | _ | _ |
| Officer | 21 | 46.7 | 24 | 53.3 | 1.53(0.71-3.31) | 0.279 | |
| Farmer | 26 | 38.8 | 41 | 61.2 | 1.11(0.55-0.24) | 0.771 | |
| Binocular good vision | Yes | 13 | 15.3 | 72 | 84.7 | 0.11(0.05- 0.23) | 0.0001* |
| No | 58 | 62.4 | 35 | 37.6 | |||
OR: odds ratio; 95% CI: confident interval;
: p < 0.05; P values were determined by Anova test.
We did not find any statistically significant relationship between severe DE disease and group of medical history including allergy, diabetes, hypertension, arthritis and other autoimmune diseases (Lupus) (p > 0.05). On the other hand, medical history of chronic conjunctivitis, refractive errors, Sjogren’s syndrome was shown to be statistically significant association with severe dry eye disease (p < 0.05) (Table 5).
Table 5.
The relationship between severe dry eye and medical history
| Risk factors | Yes | No | OR 95%CI | p | |||
|---|---|---|---|---|---|---|---|
| N | % | n | % | ||||
| Medical history | Yes | 70 | 44.9 | 86 | 55.1 | 17.09 2.24 – 130.25 | 0.0001* |
| No | 1 | 45 | 21 | 95.5 | |||
| Chronic conjunctivitis | Yes | 7 | 25.9 | 20 | 74.4 | 0.36 0.14 – 0.91 | 0.027* |
| No | |||||||
| Refractive error | Yes | 3 | 12.5 | 51 | 87.5 | 0,14 0.04 – 0.48 | 0.0001* |
| No | 67 | 51.1 | 64 | 48.9 | |||
| Allergic diseases | Yes | 13 | 32.5 | 27 | 67.5 | 0.49 0.23-1.04 | 0.062 |
| No | 57 | 49.6 | 58 | 50.4 | |||
| Diabetes | Yes | 1 | 50 | 1 | 50 | 1.2 0.07-19.59 | 1 |
| No | 69 | 45.4 | 83 | 54.6 | |||
| Hypertension | Yes | 5 | 62.5 | 3 | 37.5 | 2.1 0.48-9.13 | 0.47 |
| No | 65 | 14.2 | 82 | 55.8 | |||
| Sjogren’s syndrome | Yes | 30 | 93.8 | 2 | 6.3 | 31.13 7.08-136.76 | 0.0001* |
| No | 40 | 32.5 | 83 | 67.5 | |||
| Athritis | Yes | 22 | 46.8 | 25 | 53.2 | 1.1 0.55-2.19 | 0.786 |
| No | 48 | 44.4 | 60 | 55.6 | |||
| Other autoimmune diseases | Yes | 3 | 100 | 0 | 0 | 0.44 0.37-0.53 | 0.09 |
| No | 67 | 44.1 | 85 | 55.9 | |||
OR: odds ratio; 95% CI: confident interval;
: p < 0.05; P values were determined by Anova test.
Discussion
General information of research subjects
The mean age of participants was 44.6 years and the 40-59 age group comprised the most patients among the 3 age groups (43.7%). This characteristic is similar to a study of Alyscia Cheema [8]. DE disease can occur at any age. This study revealed the significant and important effects of dry eye disease on individual health as a public health problem. The prevalence of dry eye symptoms increased with age (p < 0.05); it is consistent with the research of BOSS [9]. The proportion of female participated in our study (80.9%) was higher than of male (19.1%). It is similar to the results of previous epidemiological studies of this disease [10], [11], [12].
Among the dry eye patients, the ratio of low education, low income was higher than the others rest. In fact, people with low educational level, low average income often work in bitter environmental conditions such as overheat, cold or outdoor sunny windy conditions. That is the cause for faster evaporation of tear film, more susceptible blepharitis which affects the adhesion forces of tear film on the corneal surface leads to DE disease. The percentage of mountainous patients who suffer from DE is very low. This may be due to not only the difficulty of mountainous people to seek medical care but also cool moist environment in the living area. Fresh climate in mountainous areas may significantly reduce the rate of DE in people living here.
More than half of our patients had good correction vision. This seems to be suitable because DE disease often insignificantly reduces the visual acuity by altering the tear film layer, not impairing the transparent environment such as cornea, lens.
Description of quality of life (QoL)related vision according OSDI
The symptoms of ocular surface with high scores and frequent occurrences make a significant impact on the QoL of patients with DE. The mean OSDI score of discomfort of ocular surface symptom group was 48.6 ± 26.15 and 73% of patients felt uncomfortable all the time. The visual disturbance was observed with 4 activities: reading, driving, working with computer and watching TV. OSDI score regarding to these categories was also less than half of the normal person (43.64). The average score of DE increased under the influence of dry, windy and low humidity environments. Therefore, to reduce the effects of DE on the QoL of patients, it is necessary to limit dry, low humidity and windy conditions in living environment (Figure 3).
Related factors with severe DE
In logistic regression analysis with univariate model, we found an association between age and severe dry eye condition (p < 0.05). When the age increased by one year, the risk of severe dry eye increased by 1.03 times. This can be explained by hormonal changes at older age which leads to hyposecretion of many exocrine glands of the body (including glands responsible for tear film secretion). This condition can cause the symptoms of dry eyes. Also, the effect of hormonal factors on women also makes the prevalence of severe dry eye in women higher than that of men in our study (64.7% in women compared to 59% in men) (Table 5).
There is a stastically difference in the prevalence of severe dry eye between education levels and occupations (p < 0.05).
On the other hand, the variations of age and binocular good vision were shown to have a statistically significant with severe dry eye disease (p < 0.05). The group with binocular good vision had lower risk (0.11 times) of dry eye disease than the group without binocular good vision.
People with a history of refractive errors are at lower risk of DE than other people due to regular examination and appropriate treatment. Sjogren’s syndrome is an autoimmune disease characterized by dry mouth and signs of dry eyes due to functional impairment of exocrine glands [13]. This syndrome is the second most common autoimmune disease after rheumatoid arthritis [11]. In our study, we have not found an association with allergic diseases, arthritis. This result is similar to the study of Biljana and colleagues [6]. We also have not found the association between dry eyes and contact lenses wearees, other autoimmune diseases (Lupus), thyroid disease because the number of each type of medical history in our study was only 1-2 people [14], [15].
In conclusion, this is one of the first studies on the quality of life of patients with dry eye in Vietnam. The main result includes: dry eyes have a significant impact on visual function and it reduces the quality of daily life of patients. The factors that have been shown to be associated with severe dry eye include age, binocular good vision, medical history, chronic conjunctivitis, refractive errors, Sjogren’s syndrome.
Footnotes
Funding: This research did not receive any financial support
Competing Interests: The authors have declared that no competing interests exist
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