Dry Eye Disease Symptoms Do Not Necessarily Increase With Age

Although dry eye disease prevalence increases with age, reported symptoms do not, according to a report published in Ophthalmology Science. The study does show that objective signs worsened for women, but not for men.

This study is a secondary examination of the Dry Eye Assessment and Management (DREAM) trial that assessed omega-3 supplements to treat DED (ClinicalTrials.gov Identifier: NCT02128763). Current investigators included all 535 DREAM participants (81.1% women, 18.9% men) in this analysis and placed them into 4 categories: participants younger than 50 years of age, those 50 to 59 years, those 60 to 69 years, and at least 70 years of age. 

At baseline, fewer members of older groups were never smokers (P <.001), although more reported hypercholesteremia, hypertension, osteoarthritis, (all P <.001) and peripheral artery disease (P =.002), as well as a higher rate of DED treatment including ocular lubricants (P =.002), and use of cyclosporine eyedrops (P =.02). Linear regression models adjusted for factors including race, sex, depression, facial rosacea, peripheral artery disease, rheumatoid arthritis, Sjögren syndrome, and smoking status.

In adjusted data for combined baseline, 6-month, and 1-year follow-ups, dry eye disease signs were significantly associated with greater age: higher mean corneal staining scores (P <.001), lower tear film break-up time (TBUT, P =.01), and increased tear osmolarity (P =.001). A composite severity score of signs comprised TBUT, corneal and conjunctival staining, Schirmer testing, and meibomian gland dysfunction. These scores, between 0 and 1, worsened with age through the age groups: 0.42, 0.52, 0.53, 0.53, respectively (P =.007).

Women had significant differences in signs between groups, but men did not. Specifically, in women, average corneal staining score increased with age (P <.001), mean TBUT decreased (P =.002), tear osmolarity rose (P <.001), as did the composite score of signs (P =.003). Men exhibited no significant differences in values for any dry eye disease sign.

Neither men nor women displayed statistically significant differences across age groups based on Ocular Surface Disease Index (OSDI) adjusted mean total score (P =.16), Brief Pain Inventory (BODI, P =.92), or BODI #3 pain value (P =.56).

“While oxidative stress, inflammation, and environmental factors may be key components as to why there is increasing severity of DED with age, it is also notable that in our study, we found that DED signs worsened with increasing age in women but not men,” according to the researchers. “There are limited reports in the literature that could partially explain this finding. One previous small study that evaluated the correlation between estrogen receptor-positive basal cells of the meibomian glands and age found that there was an increasing proportion of cells expressing estrogen receptors with increasing age, independent of gender.”

Prior studies examining meibomian gland dysfunction (MGD) have found varying results; from decreased meibum expressibility with age, to no MGD association with years of life, to more asymptomatic MGD in older men. Research exploring why signs may intensify with age have indicated oxidative stress, inflammatory processes, or cumulative exposure to eye drops, ozone, pollution, or ultraviolet radiation. Other data suggest an age-related drop in corneal sensitivity may affect symptom perception.

Limitations of this investigation included a sample that excluded individuals with less pronounced dry eye disease, and lack of information on symptoms and signs for participants before dry eye diagnosis. Strengths included detailed study of a large, multi-center cohort.