A Sydney-led, groundbreaking study published in The Ocular Surface journal has provided fresh insights into the quality-of-life burden of dry eye disease (DED) and, among many findings, discovered a weak correlation between clinical DED signs and how patients actually feel.
Using real-world data from the international Save Sight Dry Eye Registry (SSDER), the authors also identified a pressing need for individualised treatment strategies.
Professor Fiona Stapleton AO from UNSW School of Optometry and Vision Science, and Professor Stephanie Watson OAM, chief investigator of the SSDER project, led a global team of ophthalmologists, optometrists, and researchers with dry eye expertise from Australia, New Zealand, the UK, Spain, France, Germany, and Nepal who worked on the study.
The findings revealed individuals with mixed subtype DED (a combination of evaporative and aqueous-deficient DED), corneal neuropathic pain, a history of DED treatment, or past DED-related procedures had significantly worse symptoms, greater activity limitations, and reduced overall quality of life. The study was done using modern psychometric methods.
“We used Rasch analysis, a modern psychometric method, to refine commonly used dry eye assessment tools and generate reliable quality of life data,” said lead author Dr Himal Kandel from The University of Sydney.
“Our results highlight that DED is more than just a clinical condition – it significantly affects mental health, daily activities, and overall well-being.”
Key findings from the study included:
- Gender and DED: Women are diagnosed with DED more frequently than men. However, once diagnosed, the quality-of-life impacts are similar across genders.
- Impact of DED subtypes: Patients with mixed subtype DED (both evaporative and aqueous deficient) experienced worse quality of life than those with only evaporative or aqueous-deficient DED alone. This suggests that mixed DED may represent a more advanced disease stage, correlating with greater impairment.
- Correlation between signs and symptoms: The study found a weak or non-existent correlation between clinical signs of DED and patient-reported symptoms. This underscores the need for independent assessment of both in clinical practice. Some patients with mild signs reported severe symptoms, while others with severe clinical indicators reported minimal discomfort.
- Mental health impacts: Anxiety-related concerns were more prevalent and bothersome than depression-related issues in the DED population. The DED symptoms played a more significant role in mental health outcomes than clinical signs, visual acuity, or age. The findings highlighted that some patients may benefit from psychological support.
- Visual acuity and functional vision: Worse visual acuity was associated with greater activity limitations. However, visual acuity did not correlate with clinical tests scores such as tear break-up time or corneal staining. Patients with unstable tear films often report intermittent blurred vision and glare but may still achieve normal visual acuity in controlled test conditions. Functional visual acuity assessments, such as spatial contrast sensitivity and reading speed, may provide better measures of DED’s visual impact.
- Corneal neuropathic pain: Patients diagnosed with corneal neuropathic pain experienced worse symptoms, greater activity limitations, and poorer mental health compared to those without neuropathic pain.
- Patient-reported outcome measures in DED: The Ocular Surface Disease Index (OSDI), the most commonly used questionnaire for DED, may benefit from validation using modern psychometric methods to ensure it provides accurate assessments of dry eye disease-related quality-of-life impacts.
- Challenge of improving quality of life: The study emphasises the challenge of improving quality of life in patients with severe or chronic DED, particularly those who have undergone prior treatments or procedures. The findings suggest that, while DED treatments may improve quality of life, the current therapeutic strategies may not fully restore quality of life to pre-DED levels.
“These findings reinforce the need for a holistic approach to DED management,” said Prof Stapleton.
“A comprehensive assessment that includes both signs and symptoms is critical to ensure optimal patient care.”
Prof Watson, the paper’s senior author, emphasised the significance of this research in advancing real-world evidence on DED.
“This study from the international registry has established its role in benchmarking clinical practice and guiding future research. Longitudinal studies using SSDER will further enhance our understanding of treatment effectiveness and patient-centred outcomes,” she said.
“As DED continues to be a significant public health concern, studies like this pave the way for more effective, evidence-based management strategies that prioritise patient well-being and quality of life improvement.”
The full open-access article is available here.
More reading
Optometrists going back to the future on dry eye disease
An Australian ophthalmologist’s take on low light level therapy for dry eye
Nutrition and dry eye: evidence-based strategies and supplements
