Dry Eye Syndrome Preferred Practice Pattern®

AMERICAN ACADEMY™ OF OPHTHALMOLOGY Protecting Sight. Empowering Lives.™ Dry Eye Syndrome Preferred Practice Pattern® © 2018 by the American Academy of Ophthalmology Published by Elsevier Inc. https://doi.org/10.1016/j.ophtha.2018.10.023 ISSN 0161-6420/18 Secretary for Quality of Care Timothy W. Olsen, MD Academy Staff Ali Al-Rajhi, PhD, MPH Andre Ambrus, MLIS Rachel Lastra Flora C. Lum, MD Doris Mizuiri Medical Editor: Susan Garratt Approved by: Board of Trustees September 22, 2018 © 2018 American Academy of Ophthalmology® All rights reserved AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners. Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. Correspondence: Ali A. Al-Rajhi, PhD, MPH, American Academy of Ophthalmology, P. O. Box 7424, San Francisco, CA 94120-7424. E-mail: . The Cornea/External Disease Preferred Practice Pattern® Panel members wrote the Dry Eye Syndrome Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Esen K. Akpek, MD Guillermo Amescua, MD Marjan Farid, MD Francisco J. Garcia-Ferrer, MD Amy Lin, MD, Cornea Society Representative Michelle K. Rhee, MD Divya M. Varu, MD David C. Musch, PhD, MPH, Methodologist Steven P. Dunn, MD, Co-chair Francis S. Mah, MD, Co-chair The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2018. The document was edited in response to the discussion and comments. Preferred Practice Patterns Committee 2018 Robert S. Feder, MD, Chair Roy S. Chuck, MD, PhD Steven P. Dunn, MD Christina J. Flaxel, MD Francis S. Mah, MD Randall J. Olson, MD Bruce E. Prum, Jr., MD David K. Wallace, MD, MPH David C. Musch, PhD, MPH, Methodologist The Dry Eye Syndrome PPP was then sent for review to additional internal and external groups and individuals in July 2018. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered. Members of the Cornea/External Disease Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document. In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-practice-patterns). A majority (70%) of the members of the Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 had no financial relationships to disclose. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Esen K. Akpek, MD: Allergan – Grant Support; Novartis Pharma AG, Shire – Consultant/Advisor Guillermo Amescua, MD: No financial relationships to disclose Steven P. Dunn, MD: No financial relationships to disclose Marjan Farid, MD: Allergan, Bio-Tissue, Inc., Shire – Consultant/Advisor Francisco J. Garcia-Ferrer, MD: No financial relationships to disclose Amy Lin, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon Laboratories, Inc., Allergan, Bausch & Lomb, NovaBay, Shire, TearLab – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Michelle K. Rhee, MD: No financial relationships to disclose Divya M. Varu, MD: No financial relationships to disclose Preferred Practice Patterns Committee 2018 Robert S. Feder, MD: No financial relationships to disclose Roy S. Chuck, MD, PhD: Novartis Pharmaceuticals, Shire – Consultant/Advisor Steven P. Dunn, MD: No financial relationships to disclose Christina J. Flaxel, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon Laboratories, Inc., Allergan, Bausch & Lomb, NovaBay, Shire, TearLab – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Randall J. Olson, MD: No financial relationships to disclose Bruce E. Prum, Jr., MD: No financial relationships to disclose David K. Wallace, MD, MPH: No financial relationships to disclose Secretary for Quality of Care Timothy W. Olsen, MD: No financial relationships to disclose Academy Staff Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose Andre Ambrus, MLIS: No financial relationships to disclose Susan Garratt: No financial relationships to disclose Rachel Lastra: No financial relationships to disclose Flora C. Lum, MD: No financial relationships to disclose Doris Mizuiri: No financial relationships to disclose The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2018 are available online at www.aao.org/ppp. OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P291METHODS AND KEY TO RATINGS P292HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P293INTRODUCTION P294Disease Definition P294Patient Population P294Clinical Objectives P294BACKGROUND P294Prevalence and Risk Factors P294Pathogenesis P296Associated Conditions P297Natural History P299CARE PROCESS P299Patient Outcome Criteria P299Diagnosis P299History P301Examination P302Diagnostic Tests P303Classification of Dry Eye Syndrome P306Management P306Mild Dry Eye P308Moderate Dry Eye P308Severe Dry Eye P311Follow-up Evaluation P313Provider and Setting P313Counseling and Referral P313Socioeconomic Considerations P314APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA P316APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES P318APPENDIX 3. SJÖGREN SYNDROME P319APPENDIX 4. DIAGNOSTIC TESTS P321LITERATURE SEARCHES FOR THIS PPP P324RELATED ACADEMY MATERIALS P326REFERENCES P327 As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved US Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration. All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code. Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD) codes for the disease entities that this PPP covers. The intended users of the Dry Eye Syndrome PPP are ophthalmologists. Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Quality, and the American College of Physicians.3GRADE Working Group Organizations that have endorsed or that are using GRADE.http://www.gradeworkinggroup.org/Date accessed: June 19, 2018Google Scholar ♦All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.♦To rate individual studies, a scale based on SIGN1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar is used. The definitions and levels of evidence to rate individual studies are as follows: Tabled 1I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of biasI+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of biasI-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of biasII++High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalII+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causalII-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causalIIINonanalytic studies (e.g., case reports, case series) Open table in a new tab ♦Recommendations for care are formed based on the body of the evidence. The body of evidence quality ratings are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Good qualityFurther research is very unlikely to change our confidence in the estimate of effectModerate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateInsufficient qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain Open table in a new tab ♦Key recommendations for care are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do notDiscretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced Open table in a new tab ♦The Highlighted Findings and Recommendations for Care section lists points determined by the PPP panel to be of particular importance to vision and quality of life outcomes.♦All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics.♦Literature searches to update the PPP were undertaken in February 2017 and June 2018 in PubMed and the Cochrane Library. Complete details of the literature search are available at www.aao.org/ppp. Dry eye is a common ocular condition that has a substantial impact on the quality of life of afflicted individuals owing to discomfort and visual disability. Dry eye may compromise results of corneal, cataract, and refractive surgery. No single test is adequate for establishing the diagnosis of dry eye. The constellation of findings from multiple tests can add greatly to the clinician's understanding of the patient's condition. Pharmacological and procedural treatments are associated with improvements in patient symptoms and clinical signs, although chronic therapy and patient compliance are necessary in most instances. Omega-3 fatty acid products without ethyl esters have been recommended and widely used in the treatment of dry eye. However, a prospective, multicenter, masked large-scale trial of 3000 mg of omega-3 fatty acids for 12 months did not show any benefit in patient symptoms or signs over placebo.4The Dry Eye Assessment and Management Study Research Group n–3 Fatty acid supplementation for the treatment of dry eye disease.N Engl J Med. 2018; 378: 1681-1690Crossref PubMed Scopus (0) Google Scholar Topical cyclosporine treatment has long been used in the treatment of dry eye and shown to have clinical benefits. Topical cyclosporine, in some instances, leads to long-term treatment-free remission of patient symptoms and signs.5Straub M Bron AM Muselier-Mathieu A Creuzot-Garcher C Long-term outcome after topical ciclosporin in severe dry eye disease with a 10-year follow-up.Br J Ophthalmol. 2016; 100: 1547-1550Crossref PubMed Scopus (4) Google Scholar, 6Wilson SE Perry HD Long-term resolution of chronic dry eye symptoms and signs after topical cyclosporine treatment.Ophthalmology. 2007; 114: 76-79Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Lifitegrast is a lymphocyte function-associated antigen-1 antagonist developed to treat dry eye syndrome (also known as dry eye disease), but the exact mechanism of action of lifitegrast in dry eye is unknown. Topical lifitegrast 5% has been approved by the US Food and Drug Administration for treatment of dry eye. Published studies show benefit in signs (corneal and conjunctival staining) as well as symptoms (eye dryness score and ocular discomfort) over a period of 3 months.7Sheppard JD Torkildsen GL Lonsdale JD et al.Lifitegrast ophthalmic solution 5.0% for treatment of dry eye disease: results of the OPUS-1 phase 3 study.Ophthalmology. 2014; 121: 475-483Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 8Holland EJ Luchs J Karpecki PM et al.Lifitegrast for the treatment of dry eye disease: results of a phase III, randomized, double-masked, placebo-controlled trial (OPUS-3).Ophthalmology. 2017; 124: 53-60Abstract Full Text Full Text PDF PubMed Google Scholar, 9Tauber J Karpecki P Latkany R OPUS-2 Investigators et al.Lifitegrast ophthalmic solution 5.0% versus placebo for treatment of dry eye disease: results of the randomized phase III OPUS-2 study.Ophthalmology. 2015; 122: 2423-2431Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Although the drug seems to be safe over 12 months, long-term efficacy and side effects are unknown.10Donnenfeld ED Karpecki PM Majmudar PA et al.Safety of lifitegrast ophthalmic solution 5.0% in patients with dry eye disease: a 1-year, multicenter, randomized, placebo-controlled study.Cornea. 2016; 35: 741-748Crossref PubMed Scopus (46) Google Scholar Dry eye patients considering keratorefractive surgery, particularly LASIK, should be cautioned that the dry eye condition could become worse after surgery. Dry eye symptoms are common in the first few months after surgery and tend to subside with time. Patients can safely undergo LASIK surgery if a pre-existing dry eye condition can be improved preoperatively. Dry eye is one of the main reasons for patient dissatisfaction following cataract surgery.11Woodward MA Randleman JB Stulting RD Dissatisfaction after multifocal intraocular lens implantation.J Cataract Refract Surg. 2009; 35: 992-997Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar Dry eye symptoms that continue beyond the normal postoperative period of 3 months might be seen in about one third of individuals.12Iglesias E Sajnani R Levitt RC Sarantopoulos CD Galor A Epidemiology of Persistent Dry Eye-Like Symptoms After Cataract Surgery.Cornea. 2018; 37: 893-898Crossref PubMed Scopus (7) Google Scholar Baseline ocular surface and tear film parameters predict the patients at risk.13Choi YJ Park SY Jun I et al.Perioperative Ocular Parameters Associated With Persistent Dry Eye Symptoms After Cataract Surgery.Cornea. 2018; 37: 734-739Crossref PubMed Scopus (7) Google Scholar Therefore, all patients undergoing cataract surgery should be evaluated and managed for dry eye preoperatively. Approximately 1/10 patients with clinically significant dry eye have an underlying Sj□gren syndrome A recent meta-analysis found that, among autoimmune diseases, primary Sj□gren syndrome is the most strongly associated risk factor for malignancy, with an incidence rate of 18.9% (95% CI, 9.4–37.9).14Zintzaras E Voulgarelis M Moutsopoulos HM The risk of lymphoma development in autoimmune diseases: a meta-analysis.Arch Intern Med. 2005; 165: 2337-2344Crossref PubMed Scopus (464) Google Scholar Therefore timely diagnosis and appropriate management of patients with underlying Sj□gren syndrome is relevant. Dry eye disease (also known as dry eye syndrome) refers to a group of disorders of the tear film that are due to reduced tear production or tear film instability, associated with ocular discomfort and/or visual symptoms and inflammatory disease of the ocular surface. The patient population includes individuals of all ages who present with symptoms and signs suggestive of dry eye, such as ocular irritation, redness, mucus discharge, fluctuating vision, and decreased tear meniscus or plugged meibomian glands. ♦Establish the diagnosis of dry eye and differentiate it from other causes of ocular irritation and redness that may complicate both patient care and research on tear deficiency♦Identify the local and systemic causes of dry eye disease♦Recommend appropriate therapy♦Relieve discomfort♦Prevent worsening of symptoms and clinical findings♦Educate and involve the patient in the management of this disease Dry eye, either alone or in combination with other conditions, is a frequent cause of ocular irritation that leads patients to seek ophthalmologic care.15Schein OD Munoz B Tielsch JM Bandeen-Roche K West S Prevalence of dry eye among the elderly.Am J Ophthalmol. 1997; 124: 723-728Abstract Full Text PDF PubMed Google Scholar Even though these symptoms often improve with treatment, the disease usually is not curable, which may be a source of patient and physician frustration. Importantly, dry eye is also a cause of reduced visual function16Karakus SM, P.; Agrawal, D; Heinrich, C.; Ramulu, PY; Akpek, EH. Impact of Dry Eye on Prolonged Reading. Optometry and Vision Science. In Press.Google Scholar, 17Mathews PM Ramulu PY Swenor BS Utine CA Rubin GS Akpek EK Functional impairment of reading in patients with dry eye.Br J Ophthalmol. 2017; 101: 481-486Crossref PubMed Scopus (16) Google Scholar, 18Sun MJ Rubin GS Akpek EK Ramulu PY Impact of Glaucoma and Dry Eye on Text-Based Searching.Transl Vis Sci Technol. 2017; 6: 24Crossref PubMed Google Scholar, 19van Landingham SW West SK Akpek EK Munoz B Ramulu PY Impact of dry eye on reading in a population-based sample of the elderly: the Salisbury Eye Evaluation.Br J Ophthalmol. 2014; 98: 639-644Crossref PubMed Scopus (21) Google Scholar and may compromise results of corneal, cataract, and refractive surgery. Epidemiologic information on dry eye disease has been limited by lack of uniformity in its definition and the inability of any single diagnostic test or set of diagnostic tests to confirm or rule out the condition. Dry eye disease is a common condition that causes varying degrees of discomfort and visual disability. Although clinic-based studies confirm its frequency (17% of 2127 consecutive new outpatients were diagnosed with dry eye following comprehensive examination), such studies may not reflect the overall population.20Hikichi T Yoshida A Fukui Y et al.Prevalence of dry eye in Japanese eye centers.Graefes Arch Clin Exp Ophthalmol. 1995; 233: 555-558Crossref PubMed Scopus (134) Google Scholar A population-based study of dry eye conducted in Melbourne, Australia, reported that of the 926 participants aged 40 to 97 years, 16.3% had a low Schirmer test (≤8 mm) and 10.8% had a high rose bengal score (≥4 mm).21McCarty CA Bansal AK Livingston PM Stanislavsky YL Taylor HR The epidemiology of dry eye in Melbourne, Australia.Ophthalmology. 1998; 105: 1114-1119Abstract Full Text Full Text PDF PubMed Scopus (493) Google Scholar The prevalence of self-reported dry eye in 3722 participants of the Beaver Dam (Wisconsin) Eye Study varied from 8.4% of subjects younger than 60 to 19.0% of those over 80, with an overall prevalence of 14.4%.22Moss SE Klein R Klein BE Prevalence of and risk factors for dry eye syndrome.Arch Ophthalmol. 2000; 118: 1264-1268Crossref PubMed Google Scholar The Men's Health Study revealed that the prevalence of dry eye in men increased from 3.9% to 7.7% when men aged 50 to 54 were compared with men over 80 (n = 25,444). In this study, dry eye was defined as a reported clinical diagnosis or symptoms of both dryness and irritation either constantly or often.23Schaumberg DA Dana R Buring JE Sullivan DA Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies.Arch Ophthalmol. 2009; 127: 763-768Crossref PubMed Scopus (338) Google Scholar In a similar Women's Health Study of over 39,000 women, the prevalence of dry eye was 5.7% among women younger than 50 and increased to 9.8% among women over 75. In this survey, the definition used for dry eye was the same as for the Men's Health Study.24Schaumberg DA Sullivan DA Buring JE Dana MR Prevalence of dry eye syndrome among US women.Am J Ophthalmol. 2003; 136: 318-326Abstract Full Text Full Text PDF PubMed Scopus (771) Google Scholar In a clinic setting, 224 subjects identified with dry eye were far more likely to exhibit signs of evaporative dry eye resulting from meibomian gland dysfunction (MGD) than from pure aqueous deficient dry eye.25Lemp MA Crews LA Bron AJ Foulks GN Sullivan BD Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study.Cornea. 2012; 31: 472-478Crossref PubMed Scopus (203) Google Scholar Estimates of dry eye prevalence based on treatment-derived data yield much lower percentages. A study evaluating medical claims data for nearly 10 million enrollees in managed care plans found that dry eye was diagnosed or treated with punctal occlusion in 0.4% to 0.5% of the enrollees.23Schaumberg DA Dana R Buring JE Sullivan DA Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies.Arch Ophthalmol. 2009; 127: 763-768Crossref PubMed Scopus (338) Google Scholar, 24Schaumberg DA Sullivan DA Buring JE Dana MR Prevalence of dry eye syndrome among US women.Am J Ophthalmol. 2003; 136: 318-326Abstract Full Text Full Text PDF PubMed Scopus (771) Google Scholar, 26Yazdani C McLaughlin T Smeeding JE Walt J Prevalence of treated dry eye disease in a managed care population.Clin Ther. 2001; 23: 1672-1682Abstract Full Text PDF PubMed Scopus (72) Google Scholar Many risk factors for dry eye have been proposed. Older age and female gender have been identified as major risk factors.21McCarty CA Bansal AK Livingston PM Stanislavsky YL Taylor HR The epidemiology of dry eye in Melbourne, Australia.Ophthalmology. 1998; 105: 1114-1119Abstract Full Text Full Text PDF PubMed Scopus (493) Google Scholar, 22Moss SE Klein R Klein BE Prevalence of and risk factors for dry eye syndrome.Arch Ophthalmol. 2000; 118: 1264-1268Crossref PubMed Google Scholar, 26Yazdani C McLaughlin T Smeeding JE Walt J Prevalence of treated dry eye disease in a managed care population.Clin Ther. 2001; 23: 1672-1682Abstract Full Text PDF PubMed Scopus (72) Google Scholar, 27Viso E Rodriguez-Ares MT Gude F Prevalence of and associated factors for dry eye in a Spanish adult population (the Salnes Eye Study).Ophthalmic Epidemiol. 2009; 16: 15-21Crossref PubMed Scopus (97) Google Scholar, 28Xu L You QS Wang YX Jonas JB Associations between gender, ccular parameters and diseases: The Beijing Eye Study.Ophthalmic Res. 2010; 45: 197-203Crossref PubMed Scopus (12) Google Scholar, 29Moss SE Klein R Klein BE Long-term incidence of dry eye in an older population.Optom Vis Sci. 2008; 85: 668-674Crossref PubMed Scopus (138) Google Scholar A Japanese study found an increased prevalence of dry eye disease among Japanese office workers using visual display terminals.30Uchino M Schaumberg DA Dogru M et al.Prevalence of dry eye disease among Japanese visual display terminal users.Ophthalmology. 2008; 115: 1982-1988Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar Concurrent use of glaucoma medication containing benzalkonium chloride (BAK) was also shown to be a risk factor in patients.31Leung EW Medeiros FA Weinreb RN Prevalence of ocular surface disease in glaucoma patients.J Glaucoma. 2008; 17: 350-355Crossref PubMed Scopus (0) Google Scholar, 32Rossi GC Tinelli C Pasinetti GM Milano G Bianchi PE Dry eye syndrome-related quality of life in glaucoma patients.Eur J Ophthalmol. 2009; 19: 572-579Crossref PubMed Google Scholar Rheumatoid arthritis was associated with dry eye in two studies.21McCarty CA Bansal AK Livingston PM Stanislavsky YL Taylor HR The epidemiology of dry eye in Melbourne, Australia.Ophthalmology. 1998; 105: 1114-1119Abstract Full Text Full Text PDF PubMed Scopus (493) Google Scholar, 22Moss SE Klein R Klein BE Prevalence of and risk factors for dry eye syndrome.Arch Ophthalmol. 2000; 118: 1264-1268Crossref PubMed Google Scholar The Beaver Dam Eye Study found that after controlling for age and gender, smoking and multivitamin use were associated with an increased risk of dry eye, whereas caffeine use was associated with a decreased risk.22Moss SE Klein R Klein BE Prevalence of and risk factors for dry eye syndrome.Arch Ophthalmol. 2000; 118: 1264-1268Crossref PubMed Google Scholar An update to the Beaver Dam Study29Moss SE Klein R Klein BE Long-term incidence of dry eye in an older population.Optom Vis Sci. 2008; 85: 668-674Crossref PubMed Scopus (138) Google Scholar found that additional risk factors for dry eye included the use of antihistamines, antidepressant and antianxiety medications, and oral corticosteroids. Angiotensin-converting enzyme inhibitors were