Patient History, Symptoms, and Questionnaires for Dry Eye Disease

Patient History, Symptoms,
and Questionnaires for Dry Eye Disease

Kelly K. Nichols

Key Points

  1. ♦ Frequently queried symptoms in dry eye questionnaires include dryness, discomfort (irritation), grittiness, burning, stinging, ocular fatigue, itching, and light sensitivity.
  2. ♦ Frequency and severity questions (or some combination) are often asked in surveys to gain perspective on the regularity and impact of the symptoms.
  3. ♦ Environmental triggers and other associated factors, such as medication use, are generally included in surveys intended to diagnose dry eye.
  4. ♦ A universally accepted survey to either diagnose dry eye or monitor treatment effects does not exist.
  5. ♦ The Ocular Surface Disease Index, created by Allergan Inc. (Irvine, CA), has been used in U.S. Food and Drug Administration phase III clinical trials for dry eye and is available for clinical use.
  6. ♦ McMonnies Dry Eye Questionnaire is also available for clinical use and has questions about dry eye frequency as well as factors associated with dry eye disease.
  7. ♦ Important questions about patient history include worst symptom, previous dry eye diagnosis, frequency of artificial tear use, and time of day that symptoms are worst.
  8. ♦ Surveys for dry eye disease usually have higher specificity than sensitivity, indicating that anterior segment diseases with similar symptoms can be mistaken for dry eye on the basis of symptoms alone.
  9. ♦ While often not included in dry eye surveys, fluctuating vision or blurring of vision may be an important symptom.

Dry eye disease is a commonly diagnosed disorder of the anterior ocular surface characterized by symptoms of dryness, irritation (discomfort), and grittiness. During the past 15 years, research in the area of dry eye has significantly increased, largely driven by the report of the National Eye Institute/Industry Workshop on Clinical Trials in Dry Eyes.1 This workshop attempted to systematically define dry eye, to set forth a classification scheme for different types of dry eye, and to recommend diagnostic criteria for the diagnosis of dry eye for clinical researchers. While the workshop provided a framework for the study of dry eye, the report highlighted many areas in which knowledge about dry eye was lacking. The report set forth a definition of dry eye as follows: “Dry eye is a disorder of the tear film due to tear deficiency or excessive tear evaporation which causes damage to the interpalpebral ocular surface and is associated with symptoms of ocular discomfort.”

The definition states that symptoms are present and associated with ocular surface damage. However, the same report indicated that dry eye disease could be diagnosed in the absence of either symptoms or surface damage. We all have had patients for whom the dry eye symptoms outweigh the abnormal ocular signs. In contrast, some patients with severe dry eye disease with significant surface damage report symptoms that do not seem to correlate with the clinical signs. Regardless of the severity of the disorder, asking the appropriate dry eye questions can assist the clinician in the careful monitoring of change in the disorder over time or with treatment.

Understanding dry eye symptoms and a patient’s choice of words in describing how the eyes feel is a challenge. Many words in English are used to describe feelings of irritation on the ocular surface—dryness, grittiness, discomfort, burning, stinging, foreign body sensation, and itching.15 In Japan, ocular fatigue is often described as the major symptom in dry eye.6 In addition, several descriptors of the ocular surface, such as redness of the eyes, are patient symptoms of ocular surface disease but are rarely reported or recorded without direct questioning. There may be cultural differences that vary across the United States and throughout the world in the choice of words that may play a role in a patient’s description of dry eye symptoms.

Although many clinicians believe that symptoms are the hallmark of dry eye disease, symptoms often do not correlate with diagnostic tests, except in severe cases.5,79 The same symptoms are also used to describe the ocular sensation in other surface disorders. Symptom-based definitions for dry eye are thought to have lower sensitivity and higher specificity.10 That is, using symptoms alone to diagnose dry eye, patients without the disease are rarely misclassified as having the disease (specificity), and patients with the disease have the potential to be misclassified as normal (sensitivity). Investigators have developed symptom surveys in an attempt to better delineate dry eye symptoms.24,8,1126 Several of these survey instruments are similar in that many of the same symptoms are included. Several assess severity as well as frequency, either separately or as a combined variable. What is different between surveys is the subtle wording of the symptom questions, which can influence patient response and which is difficult to quantify. Therefore, it is challenging to make comparisons across surveys. In addition, the patient samples used in the development or implementation of each survey are markedly different, and many are used to diagnose dry eye rather than to detect changes or improvement with treatment.

♦ A Dry Eye-Specific Patient History

In most comprehensive eye examinations, patients are often asked if their eyes ever feel “dry.” Inquiring about symptoms of ocular discomfort is important; however, following up the initial screening question about ocular discomfort with targeted history questions and specific questions about the timing and severity of the dryness symptoms can provide the clinician with key baseline data. Although many of the diagnostic tests used to diagnose dry eye are largely unreliable for classifying patients, but when asked about dry eye symptoms, patient responses are repeatable.27 In addition, asking patients to identify their worst symptom (or symptoms) at the initial diagnosis and monitoring that symptom over time or with treatment can be a subtle indication of change in the disease process. The time of day that symptoms are worst can provide additional diagnostic information. For example, end-of-day symptoms are worse in patients with dry eye,12 whereas symptoms that are worse at different times of day may indicate other anterior segment disease. Examining patients when the symptoms are worst yields higher probability of identifying abnormalities in tear stability and damage of the ocular surface.

Table 3-1 highlights the numerous factors that have been associated with dry eye, including increasing age, gender (female), contact lens wear, previous ocular and cosmetic surgery such as laser in situ keratomileusis (LASIK) disorders of the lids (including the blink), systemic disease, medication use, and environmental stimuli.1,15,24,26,28,29 Although a clinician has limited time to ask about every scenario in a routine examination, initial screening questions about dry eye symptoms should lead into a detailed dry eye history. In summary, a dry eye case history should include questions about specific dry eye symptoms, including dry eye frequency and severity. Additional elements in the dry eye history of importance are artificial tear use, previous dry eye diagnosis, and patient perception of dry eye status.

♦ Patient-Reported Symptoms in Dry Eye Disease

Several symptoms are reported by patients with ocular surface disease. Clinically, it is difficult to ask about symptoms without “leading” the patient into a response (e.g., do your eyes feel dry?). There has been considerable discussion in academic circles about whether a patient can feel dryness. Whether the patient feels the eye is dry or has been trained to report a certain sensation as dry, the most frequently reported symptom in ocular surface disease is dryness, followed by discomfort, soreness (scratchiness and/or grittiness), light sensitivity, and often itching.2,4,30 Patients often report that these symptoms vary from day to day, change throughout the day, and are worse in the evening.2,4,30 In general, a high correlation is found between frequency, severity, and impact on daily activities across all symptoms. Because of the high correlation between frequency and severity, it may not be necessary to inquire about severity

Table 3-1 Factors Associated with Dry Eye Disease

  1. ♦ Increasing age
  2. ♦ Female gender
  3. ♦ Contact lens wear
  4. ♦ Ocular surgery
  5. ♦ LASIK surgery
  6. ♦ Cosmetic surgery
  7. ♦ Disorders of the lids
  8. ♦ Blink disorders
  9. ♦ Concurrent anterior segment disease
  10. ♦ Systemic conditions

    1. Sjögren’s syndrome
    2. Arthritis
    3. Osteoporosis
    4. Allergies
    5. Gout
    6. Nutritional deficiencies
    7. Rheumatoid arthritis
    8. Thyroid disease
    9. Crohn’s disease
    10. Acne rosacea
    11. Glaucoma
    12. Diabetes
    13. Asthma
    14. Stevens-Johnson syndrome
    15. Autoimmune disorders (e.g., lupus)

  11. ♦ Medications

    1. Oral contraceptives, hormone replacement therapy
    2. Tricyclic antidepressants
    3. Beta-blockers
    4. Diuretics
    5. High blood pressure medication
    6. Ulcer medication
    7. Oral antihistamines
    8. Decongestants
    9. Eye medication (drops)

  12. ♦ Environmental stimuli

    1. Temperature
    2. Humidity
    3. Air circulation (outdoor or heating systems)
    4. Pollutants
    5. Computer use
    6. Time of day
    7. Reading
    8. Food, drink (e.g., alcohol)
    9. Hydration


when screening for dry eye; however, monitoring improvements to severity over time or with treatment may be more important in follow-up visits.

Many clinical studies of dry eye have evaluated symptoms. In general, these studies state that overall dryness, grittiness, burning, and ocular fatigue can be associated with dry eye.5,8,11,26,31 It is also thought that the sensation of grittiness or a “sandy or gravel sensation in the eyes” may be the most predominant symptom experienced by patients with Sjögren’s disease, whereas patients with mild to moderate dry eye may experience grittiness to a lesser degree.8,32 Shimmura and coworkers found ocular fatigue to be the most frequently reported symptom in a recent study that used a facsimile survey to evaluate trends and public awareness of dry eye in Japan.26 Using this novel approach, the authors also found dry eye sensation and blurred vision to be more common in patients who think they have dry eye. Their findings are consistent with a previous study by Toda et al,6 which reported ocular fatigue as a common symptom in dry eye in Japan.

Multiple symptoms are often reported by patients. Ban-deen-Roche et al11 reported that the expression of multiple symptoms on a frequent to continuous basis was more indicative of dry eye than the presence of one symptom alone. Determining which symptom is the most bothersome can be helpful in the management process. Clinically, recording the “worst symptom” reported by patients and monitoring changes in the symptom by asking specifically about the worst symptom at follow-up visits may be one of the only subtle documentable changes following treatment.

A symptom-based diagnosis of dry eye allows masquerading disorders to be classified as dry eye. Specific symptoms were queried in an Australian study,3 and the predominant response was ocular itch, which patients believed was due primarily to hay fever. When hay fever responses were excluded, photophobia, discomfort, and dryness were the most common symptoms. In addition, ocular itch was correlated with burning and stinging. In the sample, a high percentage of patients reported allergies, and although the use of ocular antihistamines and decongestants was low, it is feasible that ocular allergy confounds the dry eye diagnosis in this sample. Also of interest, many of the patients in this sample were previous contact lens wearers who continue to express symptoms of ocular irritation. Careful evaluation is warranted for dry eye signs in patients with symptoms who are currently wearing contact lenses or who were previously unsuccessful with contact lenses.

Anterior segment disorders that masquerade as mild to moderate dry eye disease, such as blepharitis or ocular allergy, provide a universal problem in a symptom-based dry eye diagnosis in that the symptoms are similar to those found in patients with dry eye. Many clinicians also associate specific symptoms with anterior segment disorders. For example, clinicians often associate ocular itch with allergic conjunctivitis. In a study of dry eye in Australia, the predominant symptom response was ocular itch, which patients thought was primarily due to hay fever.21 When hay fever responses were excluded, photophobia, discomfort, and dryness were the most common symptoms. Other dry eye studies have also demonstrated patient-reported ocular itch,4, 43, 34 and that ocular itching was correlated with the symptoms burning and stinging. Several population-based dry eye studies have attempted to eliminate allergy patients by asking what dry eye symptoms are present that are not related to allergies.21,22 Interestingly, many patients with dry eye also have allergies15; therefore, reported ocular itch may be dry eye, allergy, or a combination of both. Vocabulary to describe the sensations of the ocular surface is limited; as a result, significant overlap exists in the symptoms for ocular disorders. Care should be taken to diagnose and manage concurrent anterior segment disease. In addition, further indepth evaluations of specific symptomatology as it relates to diseases of the ocular surface and adnexa are needed.

♦ Surveys for Dry Eye

Surveys Assessing Symptoms

Several surveys have been used in the evaluation of dry eye. An inclusive list of symptoms queried in several dry eye surveys can be seen in Table 3-2. In general, dry eye surveys can be used to screen for dry eye disease, to diagnose dry eye disease, and to monitor changes over time or with treatment. Current surveys have been specifically developed for use in diagnosis and screening, but a validated survey sensitive enough to detect statistically significant changes with treatment is not available. In addition, uniform survey use is not globally accepted, and each study uses a slightly different version than previous studies, making comparison across studies difficult. A comprehensive list of published dry eye surveys can be seen in Table 3-3.

Table 3-2 Common Symptoms Reported by Patients with Ocular Surface Disease

  1. ♦ Ache
  2. ♦ Blurry (fluctuating) vision
  3. ♦ Burning
  4. ♦ Dryness
  5. ♦ Discomfort (irritation)
  6. ♦ Foreign body sensation (sandy or gravel sensation)
  7. ♦ Grittiness
  8. ♦ Itching
  9. ♦ Ocular fatigue
  10. ♦ Pain
  11. ♦ Photophobia (light sensitivity)
  12. ♦ Redness (of the conjunctiva)
  13. ♦ Scratchiness
  14. ♦ Soreness
  15. ♦ Sticky tears
  16. ♦ Stinging
  17. ♦ Swollen, red eyelids
  18. ♦ Tiredness (ocular)
  19. ♦ Watery eyes


Surveys Used in Prevalence Studies

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Jun 4, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Patient History, Symptoms, and Questionnaires for Dry Eye Disease

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