dry eye syndrome

Description
journal

Please download to get full document.

View again

of 5
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Information
Category:

Documents

Publish on:

Views: 10 | Pages: 5

Extension: PDF | Download: 0

Share
Transcript
  Prevalence of and Risk Factors for Dry Eye Syndrome Scot E. Moss, MA; Ronald Klein, MD; Barbara E. K. Klein, MD Objective:  To examine risk factors for the prevalenceof dry eye syndrome in a population-based cohort. Methods: Theprevalenceofdryeyewasdeterminedbyhistoryatthesecondexamination(1993-1995)oftheBea-ver Dam Eye Study cohort (N=3722). Results: Thecohortwasaged48to91years(mean±SD,65±10years)and43%male.Theoverallprevalenceofdryeye was 14.4%. Prevalence varied from 8.4% in subjectsyoungerthan60yearsto19.0%inthoseolderthan80years( P  .001fortestoftrend).Age-adjustedprevalenceinmenwas11.4%comparedwith16.7%inwomen( P  .001).Af-tercontrollingforageandsex,thefollowingfactorswereindependently and significantly associated with dry eyein a logistic model: history of arthritis (odds ratio [OR],1.91; 95% confidence interval [CI], 1.56-2.33), smokingstatus(past,OR,1.22;95%CI,0.97-1.52;current,OR,1.82;95%CI,1.36-2.46),caffeineuse(OR,0.75;95%CI,0.61-0.91),historyofthyroiddisease(OR,1.41;95%CI,1.09-1.84), history of gout (OR, 1.42; 95% CI, 1.02-1.96), to-tal to high-density lipoprotein cholesterol ratio (OR, for1unit,0.93;95%CI,0.88-0.99),diabetes(OR,1.38;95%CI,1.03-1.86),andmultivitaminuse(past,OR,1.35;95%CI,1.01-1.81;current,OR,1.41;95%CI,1.09-1.82).Non-significantvariablesincludedbodymass;bloodpressure;white blood cell count; hematocrit; history of osteoporo-sis, stroke, or cardiovascular disease; history of allergies;use of antihistamines, parasympathetics, antidepres-sants, diuretics, antiemetics, or other drying drugs; alco-holconsumption;timespentoutdoors;maculopathy;cen-tral cataract; and lens surgery. Conclusion: Theresultssuggestseveralfactors,suchassmoking, caffeine use, and multivitamin use, could bestudied for preventive or therapeutic efficacy.  Arch Ophthalmol. 2000;118:1264-1268 K  ERATOCONJUNCTIVITIS sicca, or dry eye syn-drome,isacommoncom-plaint among middle-agedandolderadults,evenin the absence of diagnosed Sjo¨gren syn-drome,rheumatoidarthritis,andotherau-toimmune diseases. 1-3 It can be a cause of great discomfort and frustration, yet verylittleisknownabouttheepidemiologyof dry eye syndrome. 1,2 Thus,thepurposeofthisarticleistoestimate the prevalence of dry eye in thepopulation of the Beaver Dam Eye Studyand to explore its relationship with vari-ousriskfactors.Thesefactorsincludecar-diovasculardisease,medications,andlife-style and environment. RESULTS Thepopulationexaminedvariedinagefrom48to91years.Themeanage(±SD)was65years (±10). Men comprised 43% of thepopulation,and99%ofsubjectswerewhite.Ofthe3722participantsinthe5-yearfollow-upexamination,19weremissingin-formationondryeye.Oftheremaining3703,dry eye symptoms were present in 534(14.4%) (95% confidence interval [CI],13.3%-15.6%).Dryeyeincreasedwithagebut changed little after age 70 years( Figure1 ).Prevalenceofdryeyewashigherin women (17.0%) compared with men(11.1%; P  .001).Thisdifferencepersistedacrossallages( Figure2 ).Adjustedforage,theprevalencewas11.4%inmenand16.7%inwomen( P  .001).Wefoundnoevidencefor an age-sex interaction ( P =.26). Table 1  presents age- and sex-adjusted prevalence of dry eye by subjectcharacteristics that show a significant ornearlysignificant( P  .10)associationwithprevalence of dry eye. Among cardiovas-cular disease risk factors, serum total tohigh-density lipoprotein (HDL) choles-terol ratio was inversely associated withdry eye, and diabetes was directly associ-ated.Therewasalsoasuggestionofanin-verse association of serum total choles-terol with dry eye. Other cardiovascularriskfactorsthatwerenotsignificantlyas-sociated with dry eye ( P  .10) includedbody mass index, systolic and diastolicblood pressure, hypertension, HDL cho-lesterol, white blood cell count, hemato-crit, history of stroke, and history of car-diovascular disease (data not shown). EPIDEMIOLOGY AND BIOSTATISTICS From the Department of Ophthalmology and VisualSciences, University of Wisconsin Medical School,Madison. (REPRINTED) ARCH OPHTHALMOL/VOL 118, SEP 2000 WWW.ARCHOPHTHALMOL.COM 1264 ©2000 American Medical Association. All rights reserved. Downloaded From: on 03/22/2018  Other medical history items associated with dry eyeincluded history of arthritis, fractures, osteoporosis, goutandthyroiddisorder(Table1).Peoplewithahistoryofal-lergies did not have a significantly higher age- and sex-adjusted prevalence of dry eye (15.6%) compared withpeople without a history of allergies (14.1%;  P =.28). Inwomen,menstrualstatusandahistoryofhysterectomywithoophorectomywerenotrelatedtodryeye(datanotshown).Among medications and supplements, only antidepres-sants,aspirin,andmultivitaminsweresignificantlyornearlysignificantly associated with age- and sex-adjusted preva-lenceofdryeye(Table1).Othermedicationsthatwerenotrelated to dry eye included angiotensin-converting en-zyme inhibitors,  - or  -antiadrenergic agents, antihista-mines, antianxiety agents, calcium channel blockers, di-uretics,antiemetics,parasympatheticagents,methyldopa,reserpine, and hormone use in postmenopausal women(data not shown). The joint relationship of arthritis andaspirinusewithdryeyewasexamined.Afteradjustingforageandsex,itwasfoundthatarthritisandaspirindosewereeachindependentlyassociatedwithdryeye.Theage-andsex-adjusted prevalence of dry eye was 10.2% and 12.2%innonusersandusersofaspirin,respectively,inpeoplewith-outarthritisand19.0%and20.7%,respectively,inpeoplewith arthritis. No interaction was apparent. Among sub- jects with a history of gout, those not being treated had a SUBJECTSANDMETHODS ThemethodsusedtoidentifytheBeaverDamEyeStudypopu-lation,reasonsfornonparticipation,andcomparisonsbetweenparticipantsandnonparticipantswerepublishedpreviously. 4,5 Briefly,aprivatecensusofBeaverDam,Wis,wasconductedfromSeptember15,1987,toMay4,1988.Thecensusiden-tified5924residentsbetweentheagesof43and84years.Dur-ing a 30-month period beginning on March 1, 1988, 4926(83.1%)oftheeligibleresidentswereexamined. 4 BeginningMarch1,1993,5-yearfollow-upexaminationsbegan.Ofthe4541survivingparticipants,3684wereexaminedinthesameorderasatbaseline.Inaddition,38eligibleresidentswhohadnotparticipatedinthebaselineexaminationwereexaminedatfollow-up.Thus,3722subjectsparticipatedinthe5-yearfollow-up examination from 1993 to 1995.Boththebaselineandfollow-upexaminationsfollowedasimilarprotocol.Informedconsentwasobtainedfromeachparticipantateachexamination.Theexaminationincludedamedicalhistoryquestionnaire,measurementofheight,weight,andbloodpressure,determinationofrefractiveerrorandvi-sualacuity,dilationofthepupils,stereoscopiccolorfundusphotographsforevaluationofage-relatedmaculopathy,slit-lampandretroilluminationphotographsofthelensesforevalu-ation of cataract, and collection of urine and blood for a se-ries of standard laboratory tests.Systolic and diastolic blood pressures were the aver-agesof2measurements.Hypertensionwasdefinedasasys-tolicbloodpressureof160mmHgorgreater,adiastolicbloodpressure of 95 mm Hg or greater, or a history of hyperten-sion with use of antihypertension medications. Body masswasdefinedasweightinkilogramsdividedbythesquareof height in meters. A subject was considered to have diabetesif he or she gave a history of diabetes mellitus, was treatedwithinsulinororalhypoglycemicagentsoraspecializeddiet,or was diagnosed during the study period. The criterion fordiagnosiswasaglycosylatedhemoglobinvaluegreaterthan2 SDs above the mean for a given age-sex group and a ran-dom blood glucose level of higher than 11.1 mmol/L (200mg/dL). Arthritis, fractures, osteoporosis, gout, thyroid dis-order, and stroke were determined by history. A history of cardiovasculardiseasewasdefinedasahistoryofangina,heartattack,orstroke.Aspirinconsumptionwasevaluatedintermsofbothoverallusage(takingornottakingaspirin)anddailydosage (not taking aspirin, taking  1 aspirin every 2 days,taking1aspirinevery2days,taking1aspirineveryday,andtaking  2 aspirin every day). Heavy drinking was definedas current or past consumption of 4 or more servings of alcoholicbeveragesdaily.Theaverageweeklyconsumptionofalcoholingramswascomputedasthesumofalcoholfromeach0.355-L(12-oz)servingofbeer,0.118-L(4-oz)servingof wine, and 0.044-L (1.5 oz) serving of liquor or distilledspirits. Each serving of beer, wine, and liquor was consid-ered to contain 12.96 g, 11.48 g, and 14.00 g of alcohol, re-spectively.Acurrentorex-smokerwasanindividualwhohadsmoked at least 100 cigarettes in his or her life. Pack-yearssmoked was computed as the number of packs (20 ciga-rettes)smokedeachdaytimesthenumberofyearssmoked.Theaveragedailyconsumptionofcaffeineinmilligramswascomputedasthesumofcaffeinemilligramsfromeach0.237-L(8-oz)servingofbrewedcoffee(103mg),instantcoffee(57mg),hotoricedtea(36mg),hotchocolate(6mg),andcaf-feine-containing soda (46 mg). The heating season was de-fined as the months of October through March, when in-doorheatingsystemsareused.Age-relatedmaculopathywasdeterminedfromthestereoscopicfundusphotographsbythe Wisconsin Age-related Maculopathy Grading System. 6 Thepresenceofcataractswasevaluatedfromtheslitlampandret-roilluminationphotographs.Centralcataractwasdefinedasnuclear cataract of grade 4 or 5 or cortical or posterior sub-capsular cataract covering at least 25% of the central lens. 7 Lens surgery was defined as the absence of the lens from ei-ther eye. Glaucoma was defined as a history of glaucoma oruse of eye drops for glaucoma. Visual impairment was de-fined as a visual acuity of 20/40 to 20/200 in the better eye.Blindness was defined as 20/200 or worse.The presence of dry eye at the time of the 5-year fol-low-up examination was determined by subject self-reported history of dry eye. History of dry eye was not de-termined at baseline. Dry eye was defined as a positiveresponsetothequestion,“Forthepast3monthsorlonger,haveyouhaddryeyes?”Forsubjectsneedingfurtherprompt-ing,thiswasdescribedasa“foreignbodysensationwithitch-ing and burning, sandy feeling, not related to allergy.” Be-cause history of dry eye was not obtained until the 5-yearfollow-upexamination,allanalyseswerebasedondatafromthatexamination.Thus,theresultsarecross-sectional.Age-andsex-adjustedprevalenceofdryeyewascomputedbymul-tiple linear regression with indicator variables for sex andage groups 48 to 59, 60 to 69, 70 to 79, and 80 to 91 years.The proportion of males of 0.434 and the proportions forthe4agegroupsof0.348,0.294,0.254,and0.104,wereusedin the calculations. Mantel-Haenszel procedures, stratifiedby age and sex, were used to test for trends and general as-sociationsinage-andsex-adjustedprevalences. 8 Logisticre-gressionwasusedtoexaminetheassociationofseveralvari-ables with the prevalence of dry eye. (REPRINTED) ARCH OPHTHALMOL/VOL 118, SEP 2000 WWW.ARCHOPHTHALMOL.COM 1265 ©2000 American Medical Association. All rights reserved. Downloaded From: on 03/22/2018  significantlyhigherage-andsex-adjustedprevalenceofdryeye (20.8%), whereas those being treated had a similarprevalence (14.6%) to those without gout (14.0%).Ocularfactorsthatwereassociatedwithage-andsex-adjustedprevalenceofdryeyeincludedlenssurgery,vi-sualacuity,andtheuseofglassesorcontactlenses(Table1).Age-relatedmaculopathy,centralcataract,andahis-tory of glaucoma were not related to prevalence of dryeye (data not shown).Lifestyle and environmental factors that were exam-inedincludedalcoholconsumption,cigarettesmoking,caf-feine consumption, climatic season, and time spent out-doors.Ahistoryofheavydrinkinginthepastwasassociatedwith a higher prevalence of dry eye (Table 1). However,thecurrentamountofalcoholconsumedwasnot(datanotshown).Currentcigarettesmoking,andpossiblypastsmok-ing,wasrelatedtodryeye,aswerepack-yearssmokedandcurrentpackssmokeddaily(Table1).Forthelatter2vari-ables, the association was largely between any reportedamountsmokedandnone.Caffeineusewasassociatedwithalowerage-andsex-adjustedprevalenceofdryeye(Table1). Again, the reported amount consumed was largely ir-relevant.Subjectswhowereexaminedduringthemonthswhen indoor heating systems were in use reported moredry eye than those examined during the warmer months(Table 1). Finally, there was no association between dryeyeandtimespentoutdoorsduringthewinterorthesum-mer (data not shown). 252015105048-59 60-69 P  <.00170-79 80-91 Age, y     P   r   e   v   a    l   e   n   c   e ,    % Figure 1.  Prevalence of dry eye symptoms by age in the Beaver Dam Eye Study, 1993 to 1995.  P  values represent a test of trend. 252015105048-59 60-69Women, P  <.001Men, P  <.00170-79 80-91 Age, y     P   r   e   v   a    l   e   n   c   e ,    % Figure 2.  Prevalence of dry eye symptoms by age and sex in the Beaver Dam Eye Study, 1993 to 1995.  P  values represent a test of trend. Table 1. Age and Sex-Adjusted Prevalence of Dry Eyeby Subject Characteristics * Characteristic No.Prevalence,%  P  RR(95% CI) Total cholesterol, range,mmol/L (mg/dL)1.5-5.4 (58-209) 886 16.3 1.00 (. . .)5.4-6.1 (210-236) 938 14.5.08 0.88 (0.71-1.10)6.1-6.9 (237-265) 852 13.6 0.83 (0.66-1.04)6.9-15.5 (266-600) 922 13.5 0.83 (0.66-1.03)Total/HDL cholesterol ratio1.70:3.76 900 16.4 1.00 (. . .)3.77:4.72 896 14.7.04 0.89 (0.72-1.10)4.73:5.91 897 13.4 0.82 (0.66-1.02)5.92:40.00 898 13.3 0.79 (0.63-0.99)Diabetes statusNo 3223 14.1.05 1.00 (. . .)Yes 370 18.1 1.26 (1.00-1.58)Arthritis historyNo 2117 10.7  .001 1.00 (. . .)Yes 1559 19.5 1.80 (1.53-2.11)Thyroid diseaseNo 3202 13.6  .001 1.00 (. . .)Yes 472 20.0 1.42 (1.16-1.73)Fracture historyNo 2843 13.4  .005 1.00 (. . .)Yes 839 17.8 1.30 (1.10-1.55)Osteoporosis historyNo 3519 13.9  .005 1.00 (. . .)Yes 163 23.9 1.60 (1.20-2.12)Gout historyNo 3377 14.0.02 1.00 (. . .)Yes 313 18.7 1.33 (1.04-1.71)AntidepressantsNot taking 3502 14.1.01 1.00 (. . .)Taking 201 20.6 1.42 (1.08-1.88)Aspirin usageNo 2788 13.8.06 1.00 (. . .)Yes 911 16.4 1.18 (0.99-1.40)Aspirin dose0 2788 13.8.011.00 (. . .)  1 every other day 154 17.0 1.24 (0.87-1.77)1 every other day 570 14.8 1.06 (0.85-1.32)1 per day 107 15.0 1.07 (0.69-1.67)  2 per day 80 28.0 1.98 (1.36-2.89)Multivitamin useNever 1033 11.3  .0051.00 (. . .)Past 909 14.8 1.37 (1.08-1.74)Current 1748 16.1 1.40 (1.14-1.72)Lens surgeryNo 3343 13.8  .005 1.00 (. . .)Yes 356 20.1 1.39 (1.11-1.75)Visual acuity  20/20 2377 12.6  .0011.00 (. . .)  20/20 1111 17.8 1.37 (1.15-1.64)  20/40 101 17.4 1.19 (0.70-2.04)Blind 18 31.6 2.54 (1.10-5.88)Glasses or contactlensesNot wearing 1288 12.8.04 1.00 (. . .)Wearing 2378 15.3 1.20 (1.00-1.43)Heavy alcohol drinkinghistoryNever 3063 13.9.091.00 (. . .)Past 561 17.2 1.31 (1.02-1.68)Current 69 12.8 0.99 (0.45-2.18) (REPRINTED) ARCH OPHTHALMOL/VOL 118, SEP 2000 WWW.ARCHOPHTHALMOL.COM 1266 ©2000 American Medical Association. All rights reserved. Downloaded From: on 03/22/2018  Logisticregressionanalysisidentifiedvariablesthatweresignificantlyandindependentlyassociatedwiththepreva-lenceofdryeyesymptoms.Afterageandsexwereincludedinthemodel,otherfactorswereselectedinstepwisefash-ion.Threelevelsofcategoricalvariables,suchassmokingstatusandmultivitaminuse,wererepresentedbyapairof indicatorvariablescomparingpastuseandcurrentusewithnonuse.Theresultsoftheanalysisarepresentedin Table2 .Theoddsfordryeyeincreased35%foreachadditional10yearsofageandincreasedsimilarlyforwomen.Theoddsnearlydoubledforpersonswithahistoryofarthritis.Also,smokers, past or current users of multivitamins, personswithahistoryofgoutorthyroiddisorder,andpersonswithdiabetesweremorelikelytohavedryeye.Personsconsum-ing caffeine and persons with a higher total to HDL cho-lesterolratiowerelesslikelytohavedryeye.Aftercontrol-ling for these additional correlates, the use of antidepres-sants and aspirin were no longer significant. COMMENT Largepopulation-basedstudiesofdryeyearefew. 1,2 Clinic-based studies are unlikely to give a true representationof the prevalence of dry eye because cases of the condi-tionwouldbeexpectedtobeoverrepresented.Thepres-entstudyhastheadvantagesofbeingpopulation-based,large, having a broad age range, and having a diverse as-sortment of correlates to examine.Nevertheless,therearelimitationstothepresentstudy.First,weusedself-reportsofdryeyewithnoobjectivetest-ing.Thetestscommonlyperformed(fluoresceinorroseben-galstaining,Schirmertest,ortearfilmbreakuptime)lacksensitivitycomparedwithself-reports. 2,9 Inaddition,wefoundmanyassociationsthathavepreviouslybeenreportedsuchaswithsex,arthritis,anddiabetes,butwedidnotfindanassociationofdryeyewithahistoryofallergies,afactorthatcouldleadtomisclassification.Thus,webelieveusingsubject-reportedsymptomsisavalidapproach.Wealsowerelim-itedinthatwewerenotabletodistinguishbetweendryeyedue to deficiencies of tear production and dry eye owingtoevaporation.Riskfactorsmaydifferbetweenthese2broadsubcategories.However,theprincipalresultofthislimita-tionwouldbeaweakeningofanyassociationsfound.An-otherlimitationisthecross-sectionaldesignofthestudy.Thisprecludesusfromknowingtheantecedent-consequentrelationshipbetweenriskfactorandendpoint.Forinstance,therelationshipbetweenmultivitaminuseanddryeyemaybe the result of people with dry eye taking vitamins in anattempt to affect the condition. We found 14.4% of the population to have symp-toms of dry eye. This compares favorably with the Salis-buryEyeEvaluation(SEE)study,whichreportedthepreva-lenceofdryeyebasedonsymptomstobe15%. 1,10 However,there are differences between the studies. First, the ques-tionnaire of the SEE study asked about the frequencies of 6 symptoms. Dry eye was considered to be present if 1 ormore symptoms was reported often or all of the time. 1,10 Second,theSEEpopulationwasolder,withameanageof 73.5yearsandvaryingfrom65to84years,and15%ofthepopulationwasblack.Thesedifferencesmayaffectthecom-parability of the 2 populations. The Melbourne study re-ported a lower prevalence of dry eye based on a set of 6symptomsthatweredifferentfromthoseoftheSEEstudy. 2,10 Thatstudyfound7.4%reporting2ormoresymptomsand5.5% reporting any severe symptom not attributed to hayfever. 2 TheMelbournestudypopulationwasyounger,witha mean age of 59 years. However, this cannot entirely ac-countforthedifferenceinprevalencefromthecurrentstudy.Ourfindingofanassociationbetweenolderageandan increase in dry eye symptoms is consistent with theMelbournestudy. 2 Thisislikelyaresultofnormalchangesintearproductionandcharacteristicsassociatedwithad-vancingage.Reductionsoftearvolumeandflowandin-creasesinevaporationhavebeennotedinolderpeople. 11 One study suggests it is increased evaporation and sub-sequent increase in tear film osmolarity with age that is Table 1. Age and Sex-Adjusted Prevalence of Dry Eyeby Subject Characteristics *  (cont) Characteristic No.Prevalence,%  P  RR(95% CI) Smoking historyNever 1701 12.9.011.00 (. . .)Past 1448 15.0 1.16 (0.96-1.39)Current 548 17.6 1.44 (1.13-1.83)Pack-years smoked0 1713 12.8.031.00 (. . .)  15 695 16.3 1.28 (1.03-1.58)  37 628 15.0 1.22 (0.95-1.55)  37 625 16.4 1.29 (1.01-1.64)Current packs smokedper day0 3156 13.8.031.00 (. . .)  1 245 17.4 1.27 (0.95-1.71)  1 287 17.4 1.33 (0.98-1.80)Caffeine useNo 1478 16.6  .01 1.00 (. . .)Yes 2222 13.0 0.79 (0.68-0.93)SeasonNonheating 1980 13.1.02 1.00 (. . .)Heating 1723 15.9 1.21 (1.03-1.41) * RR indicates relative risk; CI, confidence interval; HDL, high-density lipoprotein; and ellipses, not applicable. Table 2. Prevalence of Dry Eye for a Specified Incrementin Subject Characteristics in MultivariateLogistic Regression * Characteristic Increment  P   OR 95% CI Age, y 10   .001 1.36 1.24-1.51Sex F .03 1.29 1.02-1.62Arthritis history Present   .001 1.91 1.56-2.33Smoking status Past  .001 1.22 0.97-1.52Current 1.82 1.36-2.46Caffeine use Current   .005 0.75 0.61-0.91Thyroid disease Present   .01 1.41 1.09-1.84Gout history Present .03 1.42 1.02-1.96Total/HDLcholesterol ratio1 .03 0.93 0.88-0.99Diabetes status Present .03 1.38 1.03-1.86Multivitamin use Past.03 1.35 1.01-1.81Current 1.41 1.09-1.82 * OR indicates odds ratio; CI, confidence interval; and HDL, high-density lipoprotein. (REPRINTED) ARCH OPHTHALMOL/VOL 118, SEP 2000 WWW.ARCHOPHTHALMOL.COM 1267 ©2000 American Medical Association. All rights reserved. Downloaded From: on 03/22/2018
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks