Impact of Ocular Surface Symptoms on Quality of Life in a United States Veterans Affairs Population


To evaluate the impact of ocular surface symptoms on quality of life in a veteran population receiving eye care services.


Cross-sectional survey study.


setting: Miami Veterans Affairs Medical Center (VAMC). patient population: Patients seen at the eye clinic between June and August 2010 were asked to fill out the Dry Eye Questionnaire 5 (DEQ5) and the Impact of Dry Eye on Everyday Life (IDEEL) questionnaire. main outcome measures: Correlation between ocular surface symptoms and functionality.


Four hundred eighty-nine patients elected to fill out the DEQ5 questionnaire (36% response rate). The mean age of respondents was 66 years (standard deviation 12). Ninety-four percent were male; 62% were white and 37% were black. Using the DEQ5 as a surrogate measure of ocular surface symptoms, 65% of respondents reported at least mild ocular surface symptoms (DEQ5 ≥6) and 27% of them reported severe symptoms (DEQ5 ≥12). Black subjects had a 2-fold increased risk of severe symptoms compared to white subjects (odds ratio 2.06, 95% confidence interval 1.33-3.19). Several medications were associated with a significantly increased risk of severe symptoms, including glaucoma medications (1.7-fold increase), antidepressants (2.3-fold increase), and antihistamines (2.1-fold increase). There was an inverse correlation between DEQ5 and IDEEL scores with regard to ability to perform activities of daily living (n = 391, r = −0.54, P < .001), emotional well-being (n = 386, r = −0.63, P < .001), and the ability to work (n = 205, r = −0.57, P < .001). Fifty percent of patients with severe symptoms had documentation that their symptoms were addressed during the visit.


Severe ocular surface symptoms reduce the quality of life of Miami VAMC veterans. Eye care professionals should be vigilant in eliciting ocular surface complaints from their patients.

Dry Eye Syndrome (DES) has gained recognition as a public health concern because of its high prevalence and morbidity. Several studies have demonstrated that the symptoms associated with DES, which include irritation, foreign body sensation, and blurred vision, interfere with the ability to work and carry out daily functions. A study using the Impact of Dry Eye Living Questionnaire (IDEEL), a disease-specific instrument, revealed that severe DES symptoms correlated with difficulties in physical, social, and mental functioning. A cross-sectional study of Women’s Health Study (WHS) and Physicians’ Health Study (PHS) participants found that individuals with DES were more likely to report problems with reading, computer work, and driving compared to those not affected with the disease. Such difficulties translate into a relatively lower health-related quality of life (HRQoL) compared to the general population—patients with severe dry eye symptoms have HRQoL scores in the range of conditions like class III/IV angina.

We have previously demonstrated that DES is a prevalent condition in the Miami Veterans Affairs (VA) population. The goal of the current study was to evaluate the morbidity associated with ocular surface symptoms in this population, as well as to assess accuracy of diagnosis and treatment. The Miami VA population, which is predominantly male with a large Hispanic population, differs from previously studied DES populations, which have included more women and white subjects. Furthermore, veterans have a higher prevalence of comorbidities known to be associated with DES, including depression and post-traumatic stress disorder.

As the IDEEL questionnaire has been previously used to determine the burden of disease on vision-related quality of life in population-based samples, our goal was to use this same metric to evaluate the impact of ocular surface symptoms in a clinic-based population seen for a wide range of ophthalmic conditions. Finally, to address the knowledge gap of how frequently those with severe ocular surface symptoms are diagnosed appropriately, we assessed the documentation accuracy of eye care professionals with regard to identifying and treating patients with severe symptoms.


Study Population

Patients seen in VA clinics consist of ex-military personnel but do not include or represent all former military recruits. The Miami VA eye clinic serves veterans with specific eye problems along with those needing surveillance because of medical conditions (eg, diabetes). Patients seen in the Miami VA eye clinic (by an ophthalmologist or optometrist) between June and August 2010 were invited to complete 2 questionnaires at the time of their visit, the Dry Eye Questionnaire 5 (DEQ5) and the Impact of Dry Eye Living Questionnaire (IDEEL). Of 1348 patients seen in the Miami VA eye clinic during the 3-month period, 36% (489) elected to fill out the DEQ5. To evaluate potential biases associated with incomplete patient ascertainment, demographic characteristics of DEQ5 nonresponders were collected bimonthly (every other Friday). No demographic differences were found between this group and those who elected to fill out the questionnaire ( Table 1 ). Of 489 respondents who filled out the DEQ5 questionnaire, 80% (391) elected to fill out all or part of the IDEEL quality-of-life questionnaire.


Demographic Information of Dry Eye Questionnaire 5 Responders and Nonresponders (Sampled Bimonthly)

Patient Characteristic DEQ5 Responders DEQ5 Nonresponders P Value
Age, mean ± SD (n) 66 ± 12 (465) 67 ± 11 (143) .21
Sex, % male (n) 94% (450) 94% (134) .85
% female (n) 6% (28) 6% (9)
Race, % white (n) 62% (263) 60% (83) .89
% black (n) 37% (157) 39% (54)
% other (n) 0.9% (4) 1% (4)
Ethnicity, % Hispanic (n) 15% (64) 15% (21) .94
% not Hispanic (n) 85% (377) 85% (121)

DEQ5 = Dry Eye Questionnaire 5; SD = standard deviation.

Determination of Severity of Ocular Surface Symptoms

The DEQ5 ( Supplemental Figure , available at ) is a validated questionnaire consisting of 5 questions regarding the presence and severity of eye discomfort, dryness, and tearing over a 1-month recall period. The score ranges from 0 to 22, with 0 reflecting no ocular surface symptoms and 22 reflecting a large number of symptoms. Per previously established guidelines, mild to moderate ocular surface symptoms was defined as a DEQ5 score between 6 and 11 and severe ocular surface symptoms was defined as a score of 12 or greater.

Measurement of Quality of Life

The IDEEL is a validated questionnaire that assesses QoL specific to DES. The 27 item QoL module is divided into 3 sections, which measure daily activity limitations, emotional well-being, and work limitations. For each of these 3 domains, a scale score is calculated between 0 (representing total impairment) and 100 (representing no impairment).

Data Collection

Data from the 2 questionnaires were collected at the time of the respondents’ visit and entered into a standardized database. The Veterans Affairs administrative database was used to collect other data including demographic information (age, sex, race, ethnicity), past ocular and medical history (by International Classification of Disease codes [ICD9]), medication use (by pharmacy codes), and ocular examination findings from the day the patient filled out the questionnaires.

Main Outcome Measures

The main outcome measures included ocular surface symptoms and their associated impact on functionality, and the frequency of symptom or treatment documentation in patients with severe ocular surface symptoms.

Statistical Analysis

All statistical analyses were performed using SPSS 18.0 (SPSS Inc, Chicago, Illinois, USA) statistical package. Logistic regression analysis (using the presence of severe ocular surface symptoms [DEQ5 ≥12] as the dependent variable) was used to evaluate the effect of various factors on symptoms. This methodology was also used to evaluate which factors affected the presence of documentation in patients with severe ocular surface symptoms. The correlation between ocular symptoms (DEQ5 score) and quality of life (IDEEL scores) was evaluated by the Pearson coefficient. QoL scores between the groups (severe vs no severe symptoms) were compared using the independent Student t test. Multiple linear regression analyses were performed to assess if the associations of the DEQ5 with each IDEEL domain remained after adjusting for demographic and clinical factors.


Respondents’ Population

Four hundred eighty-nine patients elected to fill out the DEQ5 questionnaire at the time of their eye clinic visit, with no statistically significant differences on select sociodemographic characteristics between study participants and those who did not complete the questionnaire ( Table 1 ). Mean respondent age was 66 years (range 23 to 95 years, standard deviation [SD] 12). Ninety-four percent were male; 62% were white and 15% were Hispanic. Among respondents with available clinical histories in the VA administrative database, 28% (133/475) carried a diagnosis of dry eye syndrome or blepharitis, or had a history of artificial tear use.

Association Between Ocular Surface Symptoms and Patient Factors

Sixty-five percent of respondents seen at the Miami VA over a 3-month period reported having ocular surface symptoms at the time of their eye clinic visit (defined as a score of 6 or greater on the DEQ5). Twenty-seven percent of respondents reported the presence of severe symptoms (defined as a score of 12 or greater on the DEQ5). Black race was associated with a 2-fold increased risk of having severe symptoms compared to white race (odds ratio [OR] 2.06, confidence interval [CI] 1.33–3.19, P value .001) ( Table 2 ). Likewise, respondents with a documented diagnosis or previous treatment for DES or blepharitis had a 3-fold risk of having severe symptoms (CI 1.92–4.52, P value <.001). The use of any glaucoma medication was associated with a 1.7 times higher risk of severe symptoms (CI 1.09-2.60, P value .02), with the highest risk (a 2.25-fold increase) associated with brimonidine use. Furthermore, an increasing number of glaucoma medications were associated with an increased percentage of severe symptoms (none: 24%, 1 drop: 28%, 2 drops: 31%, 3 drops: 30%, 4 drops: 48%, linear-trend P value .002). In a multivariable analysis considering the various glaucoma medications, brimonidine use remained the only significant predictor of severe symptoms (OR 2.26, 95% CI 1.27-4.0, P value .005). The use of antidepression and antihistamine medication increased the risk of severe ocular surface symptoms by approximately 2-fold. In a multivariable analysis, black race, history of DES, number of glaucoma medications, and use of antidepressants and antihistamines remained significant predictors of severe symptoms.


Univariable Associations Between Demographic and Clinical Factors and Severe Ocular Surface Symptoms a in Patients Seen at the Miami Veterans Affairs Medical Center Eye Clinic

Factor Number Frequency OR b (95% CI) P Value
Age, by decade 0.85 (0.71–1.02) .07
Sex, male 118 26% 1 .14
female 11 39% 1.8 (0.83–4.00)
Race, white 57 22% 1 .001
black 57 36% 2.06 (1.33–3.19)
Ethnicity, Hispanic 19 30% 1 .63
non-Hispanic 101 27% 0.87 (0.48–1.55)
DES/blepharitis, no 72 21% 1 <.001
yes 58 44% 2.9 (1.92–4.52)
Postoperative visit, c no 17 27% 1 .93
yes 115 27% 0.98 (0.54–1.77)
Ocular meds
Glaucoma medication, no 86 24% 1 .02
yes 46 35% 1.69 (1.09–2.60)
Prostaglandin, no 94 24% 1 .01
yes 38 37% 1.82 (1.14–2.89)
Dorzolamide-timolol, no 103 25% 1 .006
yes 29 40% 2.06 (1.22–3.46)
Brimonidine, no 108 25% 1 .004
yes 24 43% 2.25 (1.27–4.00)
Beta blocker, no 100 25% 1 .02
yes 32 37% 1.80 (1.10–2.94)
Depression, no 76 25% 1 .12
yes 56 31% 1.39 (0.92–2.08)
PTSD, no 116 26% 1 .40
yes 16 32% 1.31 (0.70–2.46)
Systemic meds
Anti-BPH medication, no 89 25% 1 .19
yes 43 31% 1.33 (0.86–2.06)
Anti-anxiety medication, no 106 26% 1 .17
yes 26 33% 1.44 (0.86–2.42)
Antidepression medication, no 85 23% 1 <.0005
yes 47 41% 2.31 (1.48–3.59)
Antihistamine, no 80 23% 1 .001
yes 52 38% 2.11 (1.38–3.24)

BPH = benign prostatic hyperplasia; CI = confidence interval; DES = dry eye syndrome; meds = medications; OR = odds ratio; PMH = past medical history; POH = past ocular history; PTSD = post-traumatic stress disorder.

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Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Impact of Ocular Surface Symptoms on Quality of Life in a United States Veterans Affairs Population

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