Issue: July 25, 2021
Disclosures: White reports he is a consultant to Allergan, Bausch + Lomb, Bruder, EyePoint, Eyevance, Johnson & Johnson, Kala, Novartis, Ocular Therapeutix, Omeros, Rendia, Sight Sciences, Sun and TearLab; is a speaker for Allergan, Eyevance, Kala, Novartis, Omeros and Sun; and has ownership in Ocular Science.
July 21, 2021
4 min read
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The patient burden of dry eye disease

Issue: July 25, 2021
Disclosures: White reports he is a consultant to Allergan, Bausch + Lomb, Bruder, EyePoint, Eyevance, Johnson & Johnson, Kala, Novartis, Ocular Therapeutix, Omeros, Rendia, Sight Sciences, Sun and TearLab; is a speaker for Allergan, Eyevance, Kala, Novartis, Omeros and Sun; and has ownership in Ocular Science.
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Everything about dry eye disease is hard.

Think about it. A supermajority of your peers either do not or will not treat it. Worse than that, a significant percentage of ophthalmologists and optometrists still insist that it is not a real disease. At best, this group is willing to concede that patients who have dry eye disease (DED) might be inconvenienced, that DED is a kind of “lifestyle disease” not worthy of true medical intervention. Patients themselves are often flummoxed by the diagnosis, often going to great lengths to find out what is “really” going on before accepting DED as the cause of their symptoms. Naturally, at least to your cynical East Coast-bred scribe, almost every insurance company takes advantage of this “debate” to erect barriers to treatment (more in a moment).

Darrell E. White, MD
Darrell E. White

In some ways, the very nature of DED contributes to this part of the challenge faced by patients who have DED. It is axiomatic among doctors who treat DED that the symptoms the patients describe do not necessarily correlate with the signs that we, the eye doctors who treat them, find on examination or testing. This is true not only on initial encounter but is maddeningly so on follow-up visits during which doctor and patient are evaluating the effectiveness of a chosen treatment plan. Sometimes it seems like it is a toss-up between patients who look better than they feel and those who feel better than they look. Tests that we would all like to consider objective and quantifiable such as osmolarity and MMP-9 levels suffer from this same problem.

One really does not need published data to understand the impact of severe DED on patients; one only needs to walk into an exam room occupied by one of these poor souls who have an appointment for a seventh opinion. Remember what your professor told you on your psych rotation during your third year of medical school? If you walk out of a patient interview feeling depressed, it is more likely than not that your patient’s primary diagnosis is depression. You enter the room to see these folks and are engulfed by a darkness just being in their presence.

It is as if the Dementors from Harry Potter have descended on your office.

As it turns out, there is a significant and measurable burden that is shouldered by all patients with DED, not just those with severe disease. In my reading over the last year, I came across three studies that examined the impact of DED on patients’ health, well-being and productivity while at work. The most recent of these was published in the June 2021 issue of Ophthalmology. Greco and colleagues examined and queried 535 patients with moderate or severe DED looking specifically at impairment of work productivity and general activity at baseline, 6 months and 12 months.

Needless to say, to a doctor treating patients with DED, the results were not surprising. Patients with DED reported a 24.5% impairment in their overall activity and a 19.6% reduction in workplace productivity. Higher Ocular Surface Disease Index scores correlated with greater degrees of absenteeism, “presentism” (impaired performance while at work) and general activity impairment. Indeed, impairment in productivity and general activity rose by 4.3% and 4.8% respectively for each 10-unit increase in OSDI score. The ubiquity of screen use while at work and the associated increase in DED symptoms make these findings understandable. Consistent with the inconsistencies between signs and symptoms noted above, changes in corneal staining and tear breakup time over the course of the study did not affect either activity measurement.

In the August 2020 issue of American Journal of Ophthalmology, Dana and colleagues looked at the DED burden in a large survey series that compared roughly 1,000 patients with DED with an equal number of individuals who do not report any DED at all. Quality of life and work productivity measures were obtained for both groups. As expected, those with DED had both lower overall quality of life scores and reduced work productivity when compared with those without DED. The investigators also found that the severity of dryness as measured by eye dryness score (EDS) correlated with the decrease in function and activity; subjects with higher EDS scores (more severe dryness) scored lower on both QOL and productivity. DED reduces a patient’s quality of life and can make them less productive at work.

We must admit that being treated for symptomatic DED also creates a burden for patients with the disease. Also writing in American Journal of Ophthalmology, Saldanha and colleagues found that 97% of patients diagnosed with Sjögren’s syndrome used over-the-counter eye drops, and roughly half were either using prescription treatments, had undergone dry eye treatments or both. Adhering to complex treatment protocols can feel like a full-time job. Patients are told that treatments may not bring relief for weeks to months. Visiting our offices for appointments is likely a contributor to reduced work productivity.

And it goes without saying that all of this ends up being expensive. Office and medication co-pays, cash-pay treatments such as intense pulsed light, as well as supplements and those OTC drops all cost a pretty penny. As with any disease treated with expensive medications, the American health insurance ecosystem is a large enough frustration to qualify as a negative QOL factor all on its own. Preauthorization requirements and inexplicable pharmacy protocols (eg, quoting retail prices without looking at insurance coverage) are frustrating for everyone involved.

Each “step” in insurance-directed therapy is a trip deeper into the depths of an inferno that would make Dante blush.

In the end, there are a couple of realities that should be self-evident. DED is real. It is every bit a disease, and it creates an equally real and measurable burden for those patients who have it. While the quirks of the disease can make it harder to understand for both doctor and patient alike, one must be conscious of the additional burden faced by patients whose symptoms are dismissed because of that. Societal burdens added to the mix by cynical insurance strategies and other regulatory demands further worsen the challenges faced by these patients. At a minimum, it is well past time that doctors and other health care agents acknowledge these realities.