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Dry eye questionnaires: A valuable tool for ODs
Dry eye syndrome, also known as ocular surface disease (OSD), affects as many as 60 million Americans. Many patients with dry eye syndrome remain undiagnosed and untreated, and many others treat their condition with less-than-optimal over-the-counter drops. In a busy eye care practice it can be difficult to accurately diagnose this disease.
An extensive discussion of the multiple causes of dry eye disease is beyond the scope of this article, but one should be aware of the two primary reasons for ocular dryness. The first, reduced tear film volume, is primarily caused by reduction in aqueous layer production.
The second general category of dry eye occurs secondary to excessive evaporation of tears. This evaporation is frequently due to dysfunction or, in some cases, destruction of meibomian glands, which create the lipid layer of the tear film. Transillumination of these glands may help make a differential diagnosis of dry eye.
Evaluating individuals suspected of having OSD can be a frustrating task. Clinical findings and a patient’s subjective experiences often do not correlate well.
Patients with early or moderate OSD often experience symptoms, such as burning, stinging, foreign body sensation and grittiness, that appear to be more severe than demonstrated by their clinical test results.
On the other hand, patients with severe, advanced OSD typically have the clinical signs, but because inflammation associated with the disease leads to decreased corneal sensitivity, they may not experience symptoms that reflect the severity of their disease. Despite a weak or absent correlation between symptoms and signs of dry eye, symptoms are frequently the motivation for seeking eye care and are, therefore, a critical outcome measure when assessing treatment effect.
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Questionnaires: Pros, cons
One way to improve the diagnosis and management of OSD is to use a well-designed questionnaire. The primary advantages of good questionnaires over other methods of collecting data include their comprehensiveness, cost effectiveness, ease of analysis, familiarity and reduced bias. Questionnaires cannot replace an appropriate medical history but will help to identify specific issues and can help prompt the clinician to question patients about dry eye-related symptoms. Additionally, the use of questionnaires targeted to dry eye can be a practice-builder, because without a reminder, patients may not think about their dry eye as a problem that can be treated.
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When questionnaires are standardized, the results can be compared with published data. Additionally, most questionnaires are easy to analyze: if a patient scores above a certain number, the patient is considered to have dry eye.
Questionnaires are cost effective and can be administered by office staff in the waiting room, making them a reasonably economical way to obtain useful information before the patient sees the doctor for evaluation.
Questionnaires are familiar to most people. Nearly everyone has had some experience completing questionnaires, and people understand that they are an efficient way for health care providers to gather information needed for treating their conditions.
A well-designed questionnaire has no leading questions or clues as to the “right” answer. Calculated wording of questions reduces inherent, unwanted bias in patient responses.
Questionnaires have some disadvantages as well. Generally, questionnaires are structured instruments and do not allow for qualified responses. In addition, nearly 90% of all communication is visual, but gestures and other visual cues are obviously not available with written questionnaires. Another potential problem is that some questionnaires include questions that may not be important to the clinician or the patient. Finally, some patients resist questionnaires, because they want to tell you in their own words.
Questionnaire design
It is important to understand the basics of survey design to formulate a questionnaire. The primary requirement is that the questionnaire be both sensitive and specific to detect a large percentage of patients with a given condition and accurately exclude those who do not have the condition.
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A questionnaire may also be a good measure for determining the clinical efficacy of therapeutic interventions. However, questions meant to diagnose OSD will be different than questions meant to evaluate the efficacy of a treatment. In other words, when choosing a survey instrument, it is important to match the goal (diagnosis vs. evaluating a treatment’s efficacy) with the purpose of the instrument.
In designing a questionnaire, it is essential to include clear and concise instructions for completion. These must be easy to understand, with simple and direct language, short sentences and basic vocabulary. In addition, when writing a questionnaire, as when writing anything else, transitions between questions should be smooth. Grouping similar questions will make the questionnaire easier to complete.
To avoid overly influencing patients, the title of a questionnaire for OSD should not be “Dry Eye Questionnaire,” but should be as generic as possible such as “Eye Questionnaire.” To ensure standardization, responses should be given by checking boxes or circling answers, rather than filling in blanks. For many questions, the most precise way to obtain information is to use a scaled response rather than a “yes” or “no.” Adequate space should also be included for respondents to make comments.
To design a dry eye questionnaire, we must know the common symptoms of the disease as well as the conditions frequently associated with the condition. The table on page 28 list signs and symptoms widely recognized as characteristic of OSD. Systemic conditions commonly associated with OSD and medications known to frequently cause or exacerbate OSD appear in tables on this page.
Refining a survey tool
A number of questionnaires already exist and have been studied as diagnostic tools, but all of them have limitations or drawbacks. As a result, we believe there is a need for a refined survey tool.
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In the new questionnaire we are developing, the first section deals with the patient’s signs and symptoms. The respondent grades the severity of his or her symptoms. The maximum score for this section is 48 points, and grading of this section is as follows:
Always = 4
Usually = 3
Occasionally = 2
Rarely = 1
Never = 0
The second and third sections deal with medical conditions and medications that are associated with dry eyes. Each positive response is worth one point, so that the maximum score for this section is 18 points. The final section describes symptoms that are frequently associated with dry eyes. Each question is worth one point for a total of six points.
The total number of points possible is 72. Multicenter clinical trials to evaluate this questionnaire will eventually determine the cutoff values for low, moderate and high risk for OSD. We will report those findings as they become available.
For more information:
- William Townsend, OD, practices at Advanced Eye Care in Canyon, Texas and is a consultant at the VAMC in Amarillo, Texas. He can be reached at 1801 4th Ave., Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbill1@cox.net.
- Stephen Cohen, OD, has been in private practice in Scottsdale, Arizona since 1985. He is a past-president of the Arizona Optometric Association. Dr. Cohen can be reached at 10900 N Scottsdale Rd., Ste. #301, Scottsdale, Arizona 85254; (480) 513-3937; fax: (480) 367-6711; e-mail: stephen.cohen@doctormyeyes.net.
- Arthur B. Epstein, OD, FAAO, is a founding partner of North Shore Contact Lens & Vision Consultants PC, a referral-based contact lens specialty and primary eye care practice on Long Island, N.Y. He also served as the Director of the Contact Lens Service of North Shore University Hospital, NYU School of Medicine, and is a clinical adjunct assistant professor at Northeastern State University College of Optometry, Tahlequah, Okla. Dr. Epstein can be reached at Vision Consultants, One Expressway Plaza, Ste. 100, Roslyn Heights, NY 11577; (516) 299-4540; fax: (516) 288-4542; e-mail: artepstein@artepstein.com.
References:
- Casavant J, Ousler GW, Wilcox Hagberg K, Welch D, Abelson MB. A correlation between the signs and symptoms of dry eye and the duration of dry eye diagnosis. Invest Ophthalmol Vis Sci. 2005;46 E-Abstract 4455.
- Chia EM, Mitchell P, Rochtchina E, Lee AJ, Maroun R, Wang JJ. Prevalence and associations of dry eye syndrome in an older population: The Blue Mountains Eye Study. Clin Experiment Ophthalmol. 2003;31(3):229-232.
- Dalzell MD. Dry eye: Prevalence, utilization, and economic implications. Manag Care. 2003;12(12 Suppl):9-13.
- Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol. 2004;122(3):369-373.
- Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004;23(8):762-770.
- Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among U.S. women. Am J Ophthalmol. 2003;136(2):318-326.
- Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the ocular surface disease index. Arch Ophthalmol. 2000;118(5):615-621.