The present protocol describes the cross-sectional research performed on 40 healthy subjects between the ages of 20 and 45 to assess the prevalence of dry eye syndrome (DES) during COVID-19. The OSDI survey evaluated DES, and the advanced ophthalmic systems (AOS) software was used to assess limbal redness.
The incidence of dry eye syndrome (DES) has increased due to wearing masks, utilizing digital devices, and working remotely during the pandemic. A survey was conducted during the COVID-19 pandemic to determine the prevalence of dry eye syndrome. A cross-sectional study investigated how prevalent DES is during COVID-19 in healthy patients aged 20-45 in the United States. An Ocular Surface Disease Index (OSDI) questionnaire was given to 40 individuals remotely from October 31, 2021, to December 1, 2021. The AOS and the OSDI survey were used to evaluate DES. The subjects were 29 years old on average (SD 14.14), with 23 males (57.5%) and 17 females (42.5%). According to the OSDI survey, low DES, moderate DES, and severe DES had prevalence rates of 15%, 77.5%, and 7.5%, respectively. White (W) people represent 50% of the population, while African Americans (AA) represent 35%, Asians represent 7.5%, and Hispanics represent 7.5%. Mild DES affected 77.5% of subjects, with 64.50% males and 35.50% females. According to the AOS objective grading system, mild (M) DES, moderate (MO) DES, and severe (S) DES had prevalence rates of 40%, 12.5%, and 15%, respectively. Linear regression was used to compare the two grading systems, and it demonstrated a strong relationship between the two grading systems.
COVID-19, caused by a SARS-COV-2 virus infection, was discovered in Wuhan, China, in December 2019. Meduri et al.1 reported a high prevalence rate of mild ocular symptoms in COVID-19 patients. In Italy, eye surgical procedures were reduced due to the pandemic2. Since the outbreak, many have been working from home and wearing masks as a precaution. Each of these elements and the use of digital devices and online learning3 contributed to dry eye syndrome (DES) and eye strain3,4, respectively. Furthermore, there is evidence that wearing masks can cause DES. Wearing the mask may cause tear evaporation and conjunctival discomfort5. Giannaccare et al. reported that 10.3% of the individuals had rising ocular discomfort symptoms during the pandemic, and the mean score of the OSDI was 21, with a mean age of 28.5 years old6.
A cross-sectional study in Japan reported that the percentage of Japanese women who had a combined result of definite or probable dry eye disease was 76.5%, greater than the percentage of men office employees who utilized Visual Display Terminal7. According to Inomata et al., prolonged screen exposure of more than 8 h/day has been linked to the symptomatic dry eye compared to less than 4 h/day8. The OSDI has proven to be a valid and reliable questionnaire for assessing the severity of DES9,10. The AOS software has been used to determine conjunctival hyperemia, and it has been proven to be a very valid software11.
The present study investigated how common DES is in healthy people aged 20-45. An Ocular Surface Disease Index (OSDI) questionnaire was given to 40 people remotely from October 31, 2021, to December 1, 2021, for conducting the test. The AOS and OSDI surveys were used to assess DES. Finally, the two grading methods were compared: the OSDI score and the AOS software. The participants had to first fill up an eligibility questionnaire, which included the following inclusion criteria: (1) Healthy individuals; (2) Age range of 20-45 years; (3) The participants had to be located in the United States.
The present study was conducted following the declaration of Helsinki, and the protocol was approved by the Institutional Review Board at Solutions (IRB, 2021/09/14). The study followed the reporting guidelines of the Declaration of Helsinki. All the participants provided informed consent for the questionnaire. The survey was conducted entirely online via the Internet. If the participants met the eligibility requirements, the consent forms, research project flier, and OSDI questionnaire were emailed to them. After submitting the consent forms and completing the OSDI questionnaire, a $10 gift credit card was issued online for completing the survey.
1. OSDI survey for DES evaluation
2. Determination of limbal redness via AOS software
3. Statistical analysis
The subjects were 29 years old on average (mean ± SD, 29 ± 14.14), with 23 males (57.5%) and 17 females (42.5%) (Table 2). White people account for 50% of the population, while African Americans account for 35%, Asians account for 7.5%, and Hispanics account for 7.5% (Figure 2). The average survey score of the OSDI was 6.17 ± 6.24, 37.94 ± 5.07, 46 ± 0 for low, moderate, and high (Figure 3). According to the OSDI Survey, low DES, moderate DES, and severe DES had prevalence rates of 15%, 77.5%, and 7.5%, respectively (Figure 4). Mild DES affects 77.5% of subjects, with males accounting for 64.50% and females accounting for 35.50%. The average redness score of the AOS was 0.47 ± 0.23, 1.50 ± 0.28, 2.60 ± 0.40, 3.65 ± 0.28, for Grade 0, Grade 1, Grade 2, and Grade 3 (Figure 5). According to the AOS objective grading system, mild DES, moderate DES, and severe DES had prevalence rates of 27.5%, 12.5%, and 10%, respectively (Figure 6). Linear regression was used to compare the two grading systems, and it demonstrated a strong relationship between them, with P < 0.001 statistically significant (Figure 7).
Figure 1: An example of the bulbar redness scale examination type. (A) Illustrates the redness scale. (B) Illustrates the vessels percentage. Please click here to view a larger version of this figure.
Figure 2: Pie chart showing the ethnicity of 40 healthy subjects. Please click here to view a larger version of this figure.
Figure 3: The mean of the OSDI score of the low, moderate, and high DES. Please click here to view a larger version of this figure.
Figure 4: Pie chart showing the percentage of participants' OSDI scores. The score reflects low dry eye syndrome (LDES), moderate dry eye syndrome (MODDES) score, and a severe dry eye syndrome (SDES) score. Please click here to view a larger version of this figure.
Figure 5: The mean of the AOS redness grading scale. Please click here to view a larger version of this figure.
Figure 6: The AOS software's redness score. The score shows the percentage of participants with a healthy score (H), a mild dry eye syndrome (MDES) score, a moderate dry eye syndrome (MODDES) score, and a severe dry eye syndrome (SDES) score. Please click here to view a larger version of this figure.
Figure 7: Scatter plot and linear regression comparing the OSDI score to the AOS software redness grading score. P < 0.001. Please click here to view a larger version of this figure.
Table 1: Ocular Surface Disease Index (OSDI) questionnaire used in the study. Low OSDI score (0-20 points); Moderate OSDI score (21-45 points); High OSDI score ( 46-100 points). Please click here to download this Table.
Table 2: Participants' demographics and the grading score. One subject was 18 years old. White (W), African Americans (AA), Asians (A), Hispanics(H). Please click here to download this Table.
Several previous studies have reported DES using the Schirmer test, tear break-up time (TBUT), and the OSDI score12. The present study used the AOS software to determine the DES using the limbal redness. One of the important critical protocol steps is to have a clear image of the eyes; if the image is blurry, determining the limbal redness is very challenging, and most likely, accurate readings are not obtained. When all the images are collected, one of the troubleshooting techniques is to check the images for clarity. One of the software limitations is that if the image is blurry, the readings would not be accurate, and this subject could not be used in this case.
The current study determines the relationship between the OSDI score and the AOS limbal redness. The significance of using the AOS limbal redness is that it adds more information to the OSDI score, such as the scale of the limbal redness in relation to the OSDI score.
In our experience, using both scores, the OSDI survey, and the AOS software, is critical for a successful prevalence rate of DES. The AOS limbal redness survey determines the AOS limbal redness, and the OSDI survey determines the DES grade, which can be low, moderate, or severe. In the present study, a 0-1 redness scale for grade 0, a 1-2 redness scale for grade 1, a 2-3 redness scale for grade 2, and a 3-4 redness scale for grade 3 were used. Grade 0 indicates healthy eyes with no redness, while grade 3 indicates severe redness with severe DES. The use of digital screens has been shown to decrease TBUT, ocular surface staining, and signs of meibomian gland dysfunction, all of which contribute to DES13.
In summary, the prevalence rate of 40 healthy subjects between the ages of 20-45 is high. To assess the prevalence rate of DES during COVID-19, the OSDI survey was used to evaluate DES, and AOS software was used to evaluate limbal redness. In addition, the relationship between the OSDI and AOS is linear. Finally, the AOS software could be used to determine DES and add more information to the OSDI score and TBUT. However, to determine the prevalence rate of DES in a large cohort, future studies need to be performed, including the OSDI score, TBUT score, and the AOS software. In addition, it is still necessary to further verify the reliability and applicability of the AOS software concerning the OSDI score and TBUT score before using both models in day-to-day clinical practice.
The authors have nothing to disclose.
We want to thank all the participants for their help and support in filling out the survey and sending the images of their eyes. The ERC Center grant provided funding for the IRB.
AOS SOFTWARE | Advanced Ophthalmic Systems | SPARCA | software to access limbal redness |
Microsoft excel | Microsoft | for data collection and analysis |