December 2019


Device Focus
Large study tracks dry eye’s increasing prevalence and incidence

by Vanessa Caceres EyeWorld Contributing Writer

Aqueous deficient dry eye disease (lissamine staining of cornea and conjunctiva)
Source: Vincent de Luise, MD

Dry eye clinical pearls from Drs. Farid and Honkanen

•Keep DED in mind in younger patients with ocular discomfort and pain.
•Aim for early identification of dry eye
to avoid more severe clinical problems in the future.
•Educate patients on how increased screen time may affect the occurrence
of dry eye.

A study involving the Department of Defense Military Health System found the prevalence and incidence of dry eye disease (DED) increased over time in all demographics.
Reza Dana, MD, and coresearchers also found that dry eye increased among younger patients, a group not usually associated with dry eye.
Researchers used Military Health System claims data from 2003–2015 in the retrospective, company-sponsored study published in the American Journal of Ophthalmology.1 Data included DOD service members, retirees, and their dependents. With a common employer, there is less socioeconomic disparity and the sample is geographically and demographically representative of the U.S. population, the researchers wrote.
Overall DED prevalence, as well as annual prevalence, annual incidence, and prescriptions for cyclosporine ophthalmic emulsion (Restasis, Allergan) were analyzed. “Because there is no universal diagnosis of DED, and therefore no unique diagnosis code to identify DED specifically, the present study used a combination of diagnoses, procedures, and/or prescription fills to identify patients with a high likelihood of having dry eye disease,” they wrote.
The analysis included 9.7 million beneficiaries (48% female). Among them, 20.8% were age 2–17, 34.6% were 18–39, 11.15% were 40–49, and 33.4% were 50 or older.

Crunching the numbers

The overall prevalence of DED was 5.28%. It was higher among females (7.78%) than males (2.96%). Prevalence also increased with age: 0.20%, 2.03%, 5.74%, and 11.66% for age groups 2–17, 18–39, 40–49, and 50+, respectively.
Using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision (ICD-9) and Current Procedural Terminology, the top nondriving and driving factors for dry eye disease included unspecified tear film insufficiency (88.04%), keratoconjunctivitis sicca (10.19%), rheumatoid arthritis (7.98%), and Sjögren’s sicca syndrome (6.58%).
The annual prevalence of DED increased from 0.83% in 2005 to 3.02% in 2012. Researchers also found that dry eye prevalence increased in patients under age 50—an age group not typically associated with dry eye.
There also was an increase in the annual incidence of dry eye. The increase in annual prevalence may be due to higher education and awareness of DED as a treatable condition, the researchers wrote.
“We know that dry eye disease is very prevalent, and this study clearly confirmed it,” Dr. Dana said.
Although the study had a large sample of the U.S. population, identifying a condition that may be classified under several codes was a limitation, the researchers wrote.

Weighing in

Robert Honkanen, MD, said the results confirm trends observed by other researchers and physicians. He said the prevalence of 5.28% seems lower than expected compared to other reports. “Presumably, this difference may be attributable to factors in study design, including incorporation of younger age groups in the study cohort and the strict criteria used as driving factors for DED diagnosis, which might have missed milder forms of the disease,” he said, calling the results “likely conservative.”
Marjan Farid, MD, also said the overall incidence found was lower than anticipated. “It was likely due to less identification in the earlier years. With improvement in diagnostic technology and increased therapeutic choices, DED is [now] more readily identified and treated,” she said.
The study defining dry eye as someone taking medication for it likely lowered the prevalence rate as well, considering that many patients with DED do not use medication.
The higher prevalence among females and patients over age 50 are also found among cornea and anterior segment doctors. These same doctors also observe a growth in dry eye among younger patients.
“We have definitely seen an increase of incidence over the years,” Dr. Farid said, citing better identification and an increase in risk factors.
Despite advancements in diagnosis and treatment, the study shows there still is work to be done. “Ongoing research is still needed to better define the underlying pathophysiology of this complex entity in hopes of developing new and more optimal treatments and perhaps a cure,” Dr. Honkanen said.

About the doctors

Reza Dana, MD
Claes H. Dohlman Professor of Ophthalmology
Harvard Medical School

Marjan Farid, MD
Professor of ophthalmology
Gavin Herbert Eye Institute
University of California, Irvine
Irvine, California

Robert Honkanen, MD
Department of Ophthalmology
Stony Brook Medicine
Commack, New York


1. Dana R, et al. Estimated prevalence and incidence of dry eye disease based on coding analysis of a large, all-age, United States health care system. Am J Ophthalmol. 2019;202:47–54.

Relevant financial interests

: Aldeyra Therapeutics, Dompé, Kala Pharmaceuticals, Proteris Biotech, Takeda
Farid: None
Honkanen: None

Contact information


Large study tracks dry eye’s increasing prevalence and incidence Large study tracks dry eye’s increasing prevalence and incidence
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