Appraisal of patient-reported outcome instruments available for randomized clinical trials in dry eye: revisiting the standards

Efficacy and safety of intense pulsed light delivered by the C.STIM® for treatment of Meibomian gland dysfunction

INTRODUCTION

Intense pulsed light (IPL) appears to be a promising treatment for Meibomian gland dysfunction (MGD), the most common cause of dry eye disease. C.STIM® is a new IPL device. We report the first safety and efficacy study in clinical practice.

MATERIALS AND METHODS

Patients with moderate MGD treated with C.STIM® were included. Three IPL sessions were performed at D0, D15 and D45 with 4 shots per side (fluence of 8J/cm2). Clinical evaluation was performed at D0, D45 and M3 with several parameters: BUT, OSDI and Oxford scales, meibomian gland evaluation (morphology, quality and expressibility of meibum). The Lacrydiag® imaging device was used for objective evaluation of interferometry, meibography, tear meniscus height and NIBUT. The primary endpoint was the change in NIBUT between D0 and M3. Data collection was retrospective. Longitudinal analysis and a non-parametric linear mixed-effects model (R software) were used for statistical analysis.

RESULTS

Thirty-five patients were included. NIBUT increased significantly between D0 and M3, with a mean difference of 2.6seconds (95% CI 2.0; 3.1, P<0.001). The other parameters studied also changed significantly, except for meibography (percentage of loss and morphology) and tear meniscus height. No adverse event was noted.

CONCLUSION

C.STIM® appears safe and effective in the treatment of MGD, although a randomized controlled trial is needed to validate these results.

Quality of life improvement in dry eye patients after intense pulsed light therapy compared to punctal plugs

PURPOSE

The purpose of the study was to evaluate the quality of life (QOL) improvement in evaporative dry eye patients after treatment with intense pulsed light (IPL) therapy compared to punctal plug insertion.

METHODS

A prospective comparative interventional study included 30 patients with moderate-to-severe evaporative dry eye. Patients' QOL affection before and after treatment was assessed by the Ocular Surface Disease Index (OSDI) questionnaire. Fifteen patients were treated with IPL therapy (Group 1). The other 15 patients were treated with silicone punctal plug insertion (Group 2).

RESULTS

Improvement of patients' QOL was noticed in all patients of Group 1, with significant improvement of OSDI score from a mean value of 56.9 to 22.9 (P = 0.001). Improvement was noticed in 80% of Group 2 patients (mean OSDI score pretreatment: 53.8 and posttreatment: 31.7, P = 0.017). The tear breakup time (TBUT) in Group 1 significantly improved from a mean of 3.2 s to 5.9 s (P = 0.001), whereas it showed no significant changes in Group 2 (mean TBUT pretreatment: 3.6 s and posttreatment: 3.9 s, P = 0.654). Complications occurred in 13.3% in Group 2, including punctal granuloma and proximal canalicular obstruction. No adverse effects were recorded in Group 1.

CONCLUSION

IPL therapy had better results with more improvement of patients' QOL compared to punctal plugs. It also showed a better safety profile with no reported complications.

Correlation and Level of Agreement between the Ocular Surface Disease Index and the Symptom Assessment in Dry Eye Questionnaires: A Survey-Based Study

PURPOSE

The Ocular Surface Disease Index (OSDI) is the most frequently used dry eye disease (DED) questionnaire, and the Symptom Assessment iN Dry Eye (SANDE) is the simplest and quickest to apply. We analyze the correlation and level of agreement between these two questionnaires in a large DED heterogeneous population to evaluate their performance and potential interchangeability.

METHODS

Prospective, multicenter longitudinal survey-based study performed on patients diagnosed with DED by 99 ophthalmologists from 20/32 Mexican states. Questionnaires were applied in two consecutive visits to analyze the correlation between OSDI and SANDE to evaluate patients with DED clinically. Level of agreement was evaluated with Bland-Altman analysis, and internal consistency of instruments was evaluated individually and combined with Cronbach's alpha index.

RESULTS

3421 patients studied: 1996 (58.3%) women and 1425 (41.7%) men, aged 49.5 ± 15.4 years; 995 (29.1%) patients had aqueous-deficient, 1086 (31.7%) evaporative, and 1340 (39.2%) mixed DED subtypes. Normalized baseline scores were 53.7 (OSDI) and 54.1 (SANDE). After 36.3 ± 24.4 days between visits, scores were reduced to 25.2 (OSDI) and 21.8 (SANDE) points (p < .001). A positive correlation between questionnaires was found at baseline (R = 0.592; p < .001), follow-up (R = 0.543; p < .001) and change between visits (R = 0.630; p < .001). Using both questionnaires together improved the overall reliability of symptom evaluation at baseline (α = 0.7), follow-up (α = 0.7), and both (α = 0.7), compared to individual application (OSDI α = 0.5, SANDE α = 0.6)-the same improvements applied to all DED subtypes. Bland-Altman analysis revealed a differential bias of -0.41% at baseline and +3.6% at follow-up visits between OSDI and SANDE.

CONCLUSIONS

We validated the correlation (high precision) between questionnaires in a large-scale population, demonstrating improved reliability (high accuracy) in evaluating DED when used together, challenging their interchangeable use. These results open a venue to improve recommendations toward a more precise and accurate diagnostic and therapeutic evaluation of DED by using OSDI and SANDE concurrently.

Prevalence and Risk Factors for Symptomatic Dry Eye Disease Based on McMonnies Questionnaire Among Medical Students, Saudi Arabia; a Cross-Sectional Study

Purpose

Dry eye disease (DED) is a common ocular problem that worsens patients' quality of life. This study aimed to assess DED prevalence and risk factors among medical students at the University of Tabuk.

Patients and Methods

This is an analytical, cross-sectional, survey-based study. An online questionnaire was distributed by email to all medical students at the University of Tabuk. A self-administered McMonnies questionnaire was used in the assessment.

Results

We included 247 medical students who completed the questionnaire. Most participants were females (71.3%) and were <25 years old (85.8%). DED prevalence rate was 18.2% (95% CI=13.61% to 23.61%). Furthermore, DED was found to be significantly associated with the presence of irritation of eyes when waking up from sleep (OR=19.315), sleeping with partially opened eyes (OR=19.105), redness and irritation of the eyes when swimming in chlorinated fresh water (OR=7.863), and having prescription eyedrops or other dry eye treatments (OR=3.083).

Conclusion

Our study at the University of Tabuk found that 18.2% of medical students had dry eye disease and identified the associated risk factors. Early diagnosis and treatment are crucial to prevent complications due to the high prevalence of DED.

What Are the Dry Eye Questionnaires Available in the Scientific Literature Used for? A Scoping Review

PURPOSE

Dry eye disease (DED) is a frequent chronic ophthalmic condition. Its diagnosis includes tests and patient reported outcomes (PRO) questionnaires. Although many PRO dry eye questionnaires (PRO-DEQs) are available, they differ greatly from each other and not all have been validated. The purpose of this study was to retrieve the PRO-DEQs present in the scientific literature by performing a descriptive analysis of them and identifying those with known validity and reliability characteristics and to perform a descriptive analysis of the geographic area, year of publication, and characteristics of the target population of the clinical studies that have used validated PRO-DEQs.

DESIGN

Scoping review of the literature.

METHODS

Searches were conducted in PubMed to retrieve PRO-DEQs published up to July 2018 and written in English, French, Italian or Spanish.

RESULTS

One thousand six hundred two records were identified and 973 were included in the final analysis. Of these, 56 provided information on the design and validation of PRO-DEQs and 49 PRO-DEQs were identified. Twenty-two PRO-DEQs were validated (17 original and 5 modified) and 27 had no associated design, validity, and reliability studies. Most of the validated PRO-DEQs were designed in English, the number of items varies from 1 to 57, the dimensions are generally not specified, and they are self-administered. The greatest use of validated PRO-DEQs in clinical studies has been in Asia since 2010, with the Ocular Surface Disease Index being the most used. These questionnaires have been used mostly in adults, retired professionals, and people with visual diseases to diagnose DED.

CONCLUSIONS

This study aims to encourage the use of validated PRO-DEQs to guarantee the quality of the results obtained and the comparability and replicability among studies.

A retrospective study of the efficacy of intense pulsed light delivered by the Lacrystim® for meibomian gland dysfunction therapy

Background

Meibomian gland dysfunction is the most common etiology of dry eye disease worldwide and intense pulsed light appears to be a promising treatment with encouraging results. Lacrystim® is a new IPL device (CE marking in 2019) and no studies have yet been published on it. We propose the first study on this device with an objective assessment of its efficacy and an extended follow-up over 6 months.

Methods

Patients presenting with a dry eye disease (DED) with stable mild to moderate MGD and having received Lacrystim® treatment between june 2019 and june 2020 were included. 3 IPL sessions were performed at D0, D15 and D45 with 4 shots per side at a fluence of 8 mJ/cm2. DED clinical evaluation was performed at D0, D15, D45, 3rd month and 6th month: Oxford scale and break up time, Schirmer test and Ocular Surface Disease Index (OSDI) questionnaire. Lacrydiag® imaging device carried out an objective examination of tear film: interferometry, meibography, tear meniscus height and non-invasive break up time (NIBUT). The primary endpoint was the evolution in NIBUT between the first visit D0 and 3rd month. Data collection was done retrospectively. Statistical analysis was done using a linear mixed-effects model and a non-parametric linear mixed-effects model (R software).

Results

Forthy five consecutive patients were included. NIBUT significantly increased between D0 and 3rd month: mean difference of 1.63 seconds, IC95% [0.51; 2.62], (p = 0.002) with a prolonged effect at 6th month. OSDI and OXFORD scores and interferometry were also significantly improved at 3rd month and 6th month. There was no significant change in BUT, Schirmer test and tear meniscus height. No adverse event was noted.

Conclusions

IPL delivered by Lacrystim® appears effective and safe to treat MGD although a randomized controlled trial is needed to validate its results.

Trial registration

This work was approved by a local ethics committee “Terre d’éthique” (institutional review board number: IRBN672019/CHUSTE) and registered on the clinicaltrial.gov website (NCT04147962, 01/11/2019).

Efficacy, Safety and Patient-Reported Outcomes with Preservative-Free (PF) Tafluprost or PF-Dorzolamide/Timolol Compared with Preserved Latanoprost: A Prospective Multicenter Study in Korean Glaucoma Patients with Ocular Surface Disease

To compare the efficacy, patient-reported satisfaction, and safety of preservative-free (PF)-tafluprost, PF-dorzolamide/timolol and preservative-containing (P)-latanoprost in Korean glaucoma patients with ocular surface disease (OSD). In a multicenter, prospective, interventional, non-randomized, controlled 12-week trial, 107 eligible patients received PF-tafluprost (n = 37), PF-dorzolamide/timolol (n = 34), or P-latanoprost eye drops (n = 36). Outcomes included changes from baseline in OSD Index (OSDI) scores (primary endpoint), intraocular pressure (IOP), and patient-reported treatment satisfaction, and safety at 12 weeks. At 12 weeks, the mean total OSDI and subdomain (dry eye symptoms, visual-related function, environmental triggers) scores significantly improved from baseline with PF-tafluprost and PF-dorzolamide/timolol, but not with P-latanoprost. Significantly more PF-tafluprost than P-latanoprost recipients reported ‘highly improved/improved’ satisfaction (no significant difference between PF-dorzolamide/timolol and P-latanoprost). IOP changes were comparable among all three treatment groups. No new safety concerns were observed. PF-tafluprost and PF-dorzolamide/timolol showed statistically and clinically significant reductions in OSDI compared with P-latanoprost in Korean glaucoma patients with OSD.

Outcome Measures to Assess Dry Eye Severity: A Review

Outcome measures used to assess efficacy of dry eye therapeutics have not been consistently applied in clinical settings, nor have they been shown to correlate with functional outcomes. We propose that corneal staining, a clinically meaningful dry eye parameter, should be used as a standard objective outcome measure across all clinical trials evaluating dry eye treatments. We justify this based on evidence regarding its relationship to vision and vision related quality-of-life. In addition, corneal staining has been shown to correlate with ocular surface inflammation, a well elucidated aspect of dry eye pathophysiology and an active area in therapeutics research. No one outcome measure explored herein correlates perfectly to this heterogenous disease. However, there is mounting evidence showing the correlation between corneal staining and functional visual indices. We hope that future clinical trials will standardize corneal staining as a measure to determine the efficacy of interventions and justify their clinical utility.

Thai version of the dry eye-related quality-of-life score questionnaire: preliminary assessment for psychometric properties

Background

This study aimed to develop a Thai version of the Dry Eye–Related Quality-of-Life Score (DEQS-Th) questionnaire and evaluate its validity, reliability, and feasibility among Thai participants.

Methods

The DEQS-Th, a 15-item self-report measuring dry eye and its impact on quality of life (QOL) was developed based on the DEQS. The questionnaire was divided into two subscales: Bothersome Ocular Symptoms (six questions), and Impact on Daily Life (nine questions). It employed a 5-point Likert scale, addressing on both the frequency and the degree of symptoms. Backward and forward and cultural adaptation process translation methods were employed. Thirty healthy participants were enrolled to evaluate the feasibility of the DEQS-Th in terms of difficulty and convenience. Reliability was assessed using internal consistency determined by Cronbach’s alpha, with values > 0.7 considered acceptable. Convergent validity was determined by the correlation between DEQS-Th and overall health status. Confirmatory factor analysis was conducted for its factor structure.

Results

The participants’ mean age was 38.6 ± 12.9 years, and 23 (76.7%) were females. The mean time to complete the questionnaire was 9.3 ± 2.7 min. The Cronbach’s alpha of the ocular symptoms subscale, impact on QOL subscale, and summary score on frequency and degree were 0.80 and 0.70, 0.89 and 0.89, and 0.90 and 0.89, respectively. The overall health status significantly correlated with the summary score (r = 0.564, p = .001), subscale ocular symptoms (r = 0.594, p = .001), and impact on QOL scores (r = 0.626, p < .001) of the DEQS-Th, respectively. A one-factor model fitted the data the best for both the ocular symptoms subscale (CFI = 1.000, TLI = 1.000, RMSEA = 0.000) and the impact on QOL subscale (CFI = 0.998, TLI = 0.997, RMSEA = 0.053).

Conclusion

When tested among normal participants, the DEQS-Th is a valid and reliable measurement for dry eye symptoms and impact on QOL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02077-0.

Ocular Surface Disease Index© and the five-item dry eye questionnaire: A comparison in Indian patients with dry eye disease

Purpose:

To compare the suitability of the Ocular Surface Disease Index (OSDI) and the 5-item Dry Eye Questionnaire (DEQ-5) in Indian patients with dry eyes.

Methods:

This cross-sectional study evaluated the OSDI and DEQ-5 in patients with tear film abnormalities. Tear film breakup time, tear film height, Schirmer’s I, lissamine green staining, and meibomian gland expressibility were performed on each patient.

Results:

There were 101 patients with symptoms and/or signs of tear film abnormality. Both OSDI and DEQ-5 questionnaires significantly correlated (ρ = 0.566, P < 0.0001) with each other. The OSDI questionnaire showed a good correlation with all dry eye tests, whereas the DEQ-5 correlated significantly only with the tear film breakup time and the lissamine green score. None of the questionnaires correlated with meibomian gland expressibility. The Bland–Altman analysis revealed a marginal bias (−0.01 unit) for DEQ-5. The DEQ-5 scored higher in patients with mild symptoms. While 101 (100%) patients answered all the questions in the DEQ-5, only 19 (18.8%) patients answered all the questions in the OSDI questionnaire. The least responses were recorded in the vision-function-related and environmental trigger subscales of the OSDI.

Conclusion:

The OSDI and DEQ-5 scores showed a moderate correlation. The OSDI questionnaire correlated with a higher number of dry eye tests than the DEQ-5. The large number of skipped questions in the vision-function-related and environmental trigger subscales of the OSDI suggests that the questionnaire is not adequately adapted to the Indian population. Patients with a negative OSDI score should be reassessed with the DEQ-5 to exclude symptom positivity.

A Review of Dry Eye Questionnaires: Measuring Patient-Reported Outcomes and Health-Related Quality of Life

Dry eye disease (DED) is among the most common eye diseases and is becoming increasingly prevalent. Its symptoms cause a long-term decline in patients’ health-related quality of life (HRQL). Inconsistencies often occur between the clinical findings and the subjective symptoms of DED. Therefore, a holistic, balanced, and quantitative evaluation of the subjective symptoms and HRQL using patient-reported outcome questionnaires, in addition to clinical findings, is crucial for accurate DED assessment in patients. This paper reviewed the characteristics of current dry eye questionnaires, including their objectives, number of questions, inclusion of HRQL-related items, and whether they were properly evaluated for psychometric properties. Twenty-four questionnaires were identified; among them, the following six questionnaires that included items assessing HRQL and were properly evaluated for psychometric properties are recommended: the Ocular Surface Disease Index, Impact of Dry Eye in Everyday Life, Dry Eye-Related Quality-of-life Score, University of North Carolina Dry Eye Management Scale, Chinese version of Dry Eye-Related Quality of Life, and 25-Item National Eye Institute Visual Function Questionnaire. Dry eye questionnaires have different objectives and are available in different languages. Therefore, medical practitioners should confirm the characteristics of applicable questionnaires before selecting the most appropriate ones.

Patient priorities in herpes simplex keratitis

Objective

Herpes simplex keratitis (HSK) is a sight-threatening disease and a leading cause of infectious corneal blindness. Involving patients in setting the research agenda maximises patient benefit and minimises research waste. With no published patient involvement exercises, patients' priorities in HSK are unclear. The objective of this study is to explore patients' priorities for research in HSK.

Methods

A literature review of publications in the year preceding recruitment of patients identified nine domains of research interest. A questionnaire was sent to participants asking them to rank these in order of priority. The ranking results were given a weighted-average score, and a thematic analysis was undertaken for the narrative data.

Results

Thirty-seven patients participated in the survey. Top priorities for patients were risk factors for recurrence of infection, diagnostic tests and treatment failure. The narrative data revealed three key clinical needs: difficulties in long-term symptom control, the need for rapid access care in acute infection and the desire for more accessible information.

Conclusion

This study highlighted three major issues in our current approach to HSK. First, there may be a misalignment between research efforts and patient priorities. Second, high-quality patient information is not widely available. This may hamper patients' abilities to make informed decisions and contribute towards research. Third, clinical service priorities are of equal importance to patients as research. Researchers and clinicians are encouraged to address both needs in parallel.

Ophthalmic Drug Discovery and Development: Regulatory Aspects of Patient Focused Drug Development in Ophthalmology

In 2009, members of the ophthalmic research community held a joint meeting with members of the Food and Drug Administration (FDA) and the National Eye Institute (NEI) to define and describe the types of patient-focused drug development (PFDD) tools used in ophthalmology. Since then numerous reports have been published which indicate that many of the questionnaires used for patient-reported outcomes (PROs) in ophthalmic clinical development lack rigor and reliability according to modern methods. In 2017, the FDA began development of a series of four methodological guidances for sponsors of clinical trials on the significance of PFDD. The new guidances delineate the FDA's thinking and commitments under the Prescription Drug User Fee Act to implement a more structured approach to the assessment of risks and benefits in clinical trials. In these guidances, the FDA provides steps that drug and device manufacturers should follow, not only to obtain, but also to develop reliable and validated tools that measure patients' experience in clinical trials. Subsequent efforts have resulted in the development and validation of PROs specifically for ophthalmology. The purpose of this paper is to assesses the PROs currently used in ophthalmology and to provide practical strategies for incorporating them into clinical trials.

The use of patient-reported outcome research in modern ophthalmology: impact on clinical trials and routine clinical practice

This review article considers the rising demand for patient-reported outcome measures (PROMs) in modern ophthalmic research and clinical practice. We review what PROMs are, how they are developed and chosen for use, and how their quality can be critically appraised. We outline the progress made to develop PROMs in each clinical subspecialty. We highlight recent examples of the use of PROMs as secondary outcome measures in randomized controlled clinical trials and consider the impact they have had. With increasing interest in using PROMs as primary outcome measures, particularly where interventions have been found to be of equivalent efficacy by traditional outcome metrics, we highlight the importance of instrument precision in permitting smaller sample sizes to be recruited. Our review finds that while there has been considerable progress in PROM development, particularly in cataract, glaucoma, medical retina, and low vision, there is a paucity of useful tools for less common ophthalmic conditions. Development and validation of item banks, administered using computer adaptive testing, has been proposed as a solution to overcome many of the traditional limitations of PROMs, but further work will be needed to examine their acceptability to patients, clinicians, and investigators.

The impact of dry eye disease treatment on patient satisfaction and quality of life: A review

Several aspects of the quality of life (QoL) and treatment satisfaction of patients with dry eye disease (DED) may be underestimated. Ocular symptoms, which are assessed by validated patient-reported questionnaires and may include stinging, burning, itchiness, grittiness, dryness and discomfort, reduce QoL by affecting daily activities and work productivity. Self-reported symptoms do not always correlate with post-treatment improvements in clinical measures such as tear film break-up time, inflammation and osmolarity. Thus, treatments may improve clinical ocular features without improving symptoms that affect daily life. This review explores 1500 abstracts from congress presentations and peer-reviewed journals for QoL and treatment satisfaction data on the use of active lubricants, osmoprotectants, secretagogues, and immunomodulators present in topical formulations for DED treatment, and validated symptom questionnaires. Patient-reported symptoms of DED are generally improved after treatment with topical formulations for tear replacement, tear stimulation or anti-inflammatory therapy compared with baseline or a control treatment. However, more data are required to compare the performance of active ingredients. It is fundamental to diagnose patients with DED accurately, recognising the major cause behind their dry eyes. Studies are also necessary to identify how patient satisfaction and QoL may be improved through long-term use of topical preparations. We conclude that careful and thorough consideration of patient-reported symptoms should be integrated into DED management to help tailor treatment to patient needs.

Prevalence and risk factors of dry eye disease in North India: Ocular surface disease index-based cross-sectional hospital study

Purpose:

This study aims to study the prevalence of DED and analyze risk factors in North Indian population.

Methods:

This was a cross-section hospital-based, observational study. Cases enrolled over 2 years (systematic random sampling) were administered ocular surface disease index questionnaire to evaluate the prevalence and risk factors of DED. Schirmer's test and tear break-up time were performed only in the subset of patients giving consent. Categorical data were assessed with Chi-square/Fisher's Exact test, and odds ratio was analyzed using bivariate and multivariate logistic regression. P < 0.05 was statistically significant.

Results:

A total of 15,625 patients were screened. The prevalence of DED was 32% (5000/15625); 9.9% (496/5000) had mild DED; 61.2% (3060/5000) had moderate DED; and 28.9% (1444/5000) had severe DED. Age group of 21–40 years, male sex, urban region, and desk job were associated with increased risk of DED. Hours of visual display terminal (VDT) usage significantly correlated with DED (P < 0.001), and 89.98% of patients with 4 h or more of VDT use had severe dry eye. Cigarette smoking and contact lens usage had increased odds of developing severe DED (P < 0.001). Objective tests were undertaken in 552 patients; of these, 81.3% (449/552) had severe DED.

Conclusions:

The prevalence of DED in North India is 32%, with the age group of 21–40 years affected most commonly. VDT use, smoking, and contact lens use were associated with increased odds of developing DED.

Determination of the Minimal Clinically Important Difference of the University of North Carolina Dry Eye Management Scale

PURPOSE

To establish an initial estimation of the MCID of the University of North Carolina Dry Eye Management Scale (UNC DEMS) and assess its association with patient perceptions of symptom change.

METHODS

Thirty-three patients (33.3% men, 67.7% women, mean age 60.5 yrs) with previous DEMS scores were recruited from a UNC ophthalmology clinic in spring 2014. We used anchor-based methods, categorizing important symptom change, to compare the change in the DEMS scores across visits to patient assessments of change; linear regression coefficients estimated the MCID. We correlated clinical assessments, patient perceptions, and DEMS scores.

RESULTS

DEMS score changes correlated with global anchors [-0.4229 (P = 0.014)]. Unadjusted linear regression yielded a beta coefficient of -0.54 (confidence interval, -0.97 to -0.12, R = 0.18, P = 0.014), which estimated the DEMS MCID. Adjusting the regression model for days since the last visit and DEMS score improved the association (beta = -0.56; confidence interval, -0.99 to -0.13; R = 0.43; P = 0.013). Descriptive statistics produced an MCID of 1 point. Patients said that 2 points would represent a significant change. The DEMS modestly correlated with the Schirmer test (-0.4045, P = 0.0266), Oxford Grading Scheme (+0.3713, P = 0.0364), and tear breakup time (-0.3559, P = 0.0456).

CONCLUSIONS

The UNC DEMS is a valid, responsive patient-reported outcome measure instrument, which is easy to use in the clinic and capable of showing an MCID of 1 point.

Self versus examiner administration of the Ocular Surface Disease Index©

PURPOSE

To compare the difference in Ocular Surface Disease Index^© (OSDI) scores when participants were given the OSDI to complete on their own (self-guided, SG), versus under the guidance of the examiner (examiner-guided, EG).

METHODS

100 participants enrolled in this prospective two-visit study (fifty under-45 years old, 38F/12M; and fifty 45 years-and-older, 42F/8M). Participants who scored ≥1 on the Subjective Evaluation of Symptoms of Dryness (SESoD) were included in this study. Participants completed the OSDI SG during the first visit. Participants returned the next day and repeated the OSDI, but with EG (with standardized instructions). Participants were under deception and believed that they were comparing the OSDI to the SESoD.

RESULTS

The mean OSDI score of the SG and EG administration was 32.0±17.3 and 33.8±19.6 respectively (p>0.05) with 95% limits of agreement between -20.6 and +24.2. The correlation between SG and EG administration was Spearman's r=0.81, p<0.01. The mean difference between SG and EG was not significant (p>0.05) for both the under-45 group, and 45-and-older group. The 95% limits of agreement for the under-45 group were smaller than the 45-and-older group (under-45: [-15.5, +13.1,], 45-and-older: [-23.3, +32.2]). A significant difference was found between 8 of the 12 questions items (all p≤0.01). However, the mean difference for each was <0.6 and was not considered to be clinically significant.

CONCLUSION

There was no clinically significant difference in OSDI score between SG and EG administration, however having instructions provided with EG administration affected variability of scores in the older group more than the younger group.

Reliability and Validity of the Visual, Musculoskeletal, and Balance Complaints Questionnaire

Purpose

To evaluate the reliability and validity of the 15-item Visual, Musculoskeletal, and Balance Complaints Questionnaire (VMB) for people with visual impairments, using confirmatory factor analysis (CFA) and with Rasch analysis for use as an outcome measure.

Methods

Two studies evaluated the VMB. In Study 1, VMB data were collected from 1249 out of 3063 individuals between 18 and 104 years old who were registered at a low vision center. CFA evaluated VMB factor structure and Rasch analysis evaluated VMB scale properties. In Study 2, a subsample of 52 individuals between 27 and 67 years old with visual impairments underwent further measurements. Visual clinical assessments, neck/scapular pain, and balance assessments were collected to evaluate the convergent validity of the VMB (i.e. the domain relationship with other, theoretically predicted measures).

Results

CFA supported the a priori three-factor structure of the VMB. The factor loadings of the items on their respective domains were all statistically significant. Rasch analysis indicated disordered categories and the original 10-point scale was subsequently replaced with a 5-point scale. Each VMB domain fitted the Rasch model, showing good metric properties, including unidimensionality (explained variances ≥66% and eigenvalues <1.9), person separation (1.86 to 2.29), reliability (0.87 to 0.94), item fit (infit MnSq’s >0.72 and outfit MnSq’s <1.47), targeting (0.30 to 0.50 logits), and insignificant differential item functioning (all DIFs but one <0.50 logits) from gender, age, and visual status. The three VMB domains correlated significantly with relevant visual, musculoskeletal, and balance assessments, demonstrating adequate convergent validity of the VMB.

Conclusions

The VMB is a simple, inexpensive, and quick yet reliable and valid way to screen and evaluate concurrent visual, musculoskeletal, and balance complaints, with contribution to epidemiological and intervention research and potential clinical implications for the field of health services and low vision rehabilitation.

Improvements in Signs and Symptoms of Dry Eye after Instillation of 2% Rebamipide

PURPOSE

Because dry eye greatly reduces quality of life, this study aimed to examine rebamipide instillation in patients with dry eye and assess the improvement of signs and symptoms as evaluated with the Ocular Surface Disease Index, which is the most popular index and is highly reliable.

METHODS

From June 2013 through January 2014, we examined 50 eyes of 25 patients with dry eye (6 men and 19 woman) at our institution. Dry eye was diagnosed on the basis of the presence of symptoms, tear dynamics, and ocular surface abnormalities according to the Japanese criteria for dry eye. Before being enrolled, all patients underwent ocular surface health assessment, including history interviews, and completed the Ocular Surface Disease Index questionnaire. Patients received 2% rebamipide ophthalmic solution 4 times daily for 4 weeks. Signs and symptoms were analyzed before and 4 weeks after rebamipide administration. Tear dynamics, tear break-up time, and ocular surface abnormalities were measured and compared between before and 4 weeks after rebamipide administration.

RESULTS

Of the 25 patients, 9 had definite dry eye and 16 had probable dry eye. Tear break-up time and the fluorescein staining score significantly improved after 4 weeks. However, no significant change was observed for the Schirmer test I and the lissamine green staining score.

CONCLUSIONS

The administration of 2% rebamipide 4 times daily for 4 weeks improves the signs and symptoms of dry eye and improves patients' quality of life.

Instrument development of the UNC Dry Eye Management Scale

PURPOSE

Dry eye disease (DED) is a common ocular disease that can have adverse effects on quality of life. Our aim was to develop a single-item questionnaire that is reliable, patient-driven, and clinic friendly to assess DED symptoms and their effect on quality of life to help support the management of patients with DED.

METHODS

An initial dry eye questionnaire was created and administered to 18 patients with DED followed by a 15-minute cognitive interviewing session. This questionnaire was then refined using feedback obtained from the cognitive interview and was termed the University of North Carolina Dry Eye Management Scale (UNC DEMS). Field testing was then performed on 66 patients (46 with DED and 20 without DED) to determine the validity and test-retest reliability of the UNC DEMS compared with the current gold standard, the Ocular Surface Disease Index (OSDI). Pearson correlation coefficients were calculated between the UNC DEMS, OSDI, and other DED measures to assess criterion-related validity. Reliability coefficients were estimated for test-retest reliability.

RESULTS

Comparing the UNC DEMS with the OSDI across all study participants, the correlation coefficient was 0.80 (P < 0.001). Comparing the UNC DEMS with the OSDI in the DED group, the correlation coefficient was 0.69 (P < 0.001). The test-retest reliability coefficient of the UNC DEMS was estimated to be 0.90.

CONCLUSIONS

The UNC DEMS is a valid, reliable questionnaire that can be efficiently administered in a busy clinical practice and can be used to support the management of patients with DED.

A review of quality of life measures in dry eye questionnaires

PURPOSE

Dry eye disease (DED) is an ocular disease that affects 5% to 17% of the US population. Because of the negative effects of DED on patients' quality of life (QOL), disease-specific questionnaires that assess QOL in patients with dry eyes are essential in the monitoring and management of this chronic ocular condition. This review provides clinicians and researchers with a summary of the current questionnaires available for assessing QOL in patients with dry eyes.

METHODS

A systematic review of the literature was performed in March 2013.

RESULTS

There are only 2 validated, reliable dry eye questionnaires with QOL measures currently available for clinic use: the Ocular Surface Disease Index (OSDI) and the Impact of Dry Eye on Everyday Life questionnaire (IDEEL). Multiple other dry eye questionnaires assess some degree of QOL, but they have either not been tested for validity and reliability or are limited in QOL measures they assess.

CONCLUSIONS

The OSDI and IDEEL are validated, reliable disease-specific questionnaires that assess QOL measures in patients with DED. Because of its extensive development process and multiple QOL measures, the IDEEL offers a more thorough assessment of the effect of DED on QOL for clinical trials, whereas the OSDI may be the more convenient option for clinical use as a result of its shorter completion time. Other questionnaires used to assess QOL in DED (eg, 25-item National Eye Institute Visual Function Questionnaire and Texas Eye Research and Technology Center DEQ) are fairly limited in this assessment. Finally, because of the negative effects of DED on QOL, this review emphasizes the importance of including QOL measures in future questionnaires for the monitoring and management of DED.

Rethinking dry eye disease: a perspective on clinical implications

Publication of the DEWS report in 2007 established the state of the science of dry eye disease (DED). Since that time, new evidence suggests that a rethinking of traditional concepts of dry eye disease is in order. Specifically, new evidence on the epidemiology of the disease, as well as strategies for diagnosis, have changed the understanding of DED, which is a heterogeneous disease associated with considerable variability in presentation. These advances, along with implications for clinical care, are summarized herein. The most widely used signs of DED are poorly correlated with each other and with symptoms. While symptoms are thought to be characteristic of DED, recent studies have shown that less than 60% of subjects with other objective evidence of DED are symptomatic. Thus the use of symptoms alone in diagnosis will likely result in missing a significant percentage of DED patients, particularly with early/mild disease. This could have considerable impact in patients undergoing cataract or refractive surgery as patients with DED have less than optimal visual results. The most widely used objective signs for diagnosing DED all show greater variability between eyes and in the same eye over time compared with normal subjects. This variability is thought to be a manifestation of tear film instability which results in rapid breakup of the tearfilm between blinks and is an identifier of patients with DED. This feature emphasizes the bilateral nature of the disease in most subjects not suffering from unilateral lid or other unilateral destabilizing surface disorders. Instability of the composition of the tears also occurs in dry eye disease and shows the same variance between eyes. Finally, elevated tear osmolarity has been reported to be a global marker (present in both subtypes of the disease- aqueous-deficient dry eye and evaporative dry eye). Clinically, osmolarity has been shown to be the best single metric for diagnosis of DED and is directly related to increasing severity of disease. Clinical examination and other assessments differentiate which subtype of disease is present. With effective treatment, the tear osmolarity returns to normal, and its variability between eyes and with time disappears. Other promising markers include objective measures of visual deficits, proinflammatory molecular markers and other molecular markers, specific to each disease subtype, and panels of tear proteins. As yet, however, no single protein or panel of markers has been shown to discriminate between the major forms of DED. With the advent of new tests and technology, improved endpoints for clinical trials may be established, which in turn may allow new therapeutic agents to emerge in the foreseeable future. Accurate recognition of disease is now possible and successful management of DED appears to be within our grasp, for a majority of our patients.