I recently contracted a severe form of adenoviral keratoconjunctivitis from one of my patients. This condition, which initially affected my right eye and then spread to the fellow eye, led to a dense keratitis that significantly reduced my vision, especially in the right eye. Other complications included pseudomembranes, pharyngitis, low-grade fever, and generalized malaise.

The treatment, 5% povidone iodine applied directly onto the ocular surface, destroys viral DNA and proteins; unfortunately, it had a similar effect on my ocular surface. In the ensuing days and weeks, I developed severe dry eye, especially in my right eye. At times, my best-corrected vision in the right eye was only 20/200. I began to experience depression. This experience gave me a personal glimpse into the emotional and psychological changes that many dry eye patients continually experience.

The Effects Run Deep

The association of psychological changes with dry eye is not new. In 1988, Angelopoulos et al described increased levels of anxiety, depression, and somatization in patients diagnosed with Sjögren’s syndrome (SS). The following year, Drosos et al reported elevated levels of paranoid ideation, somatization, and obsessive compulsive disorder in SS patients compared to healthy controls and to cancer patients. Note that although SS and cancer are both serious and often chronic illnesses, the cancer patients did not present with psychiatric disorders.

Hallak et al (2015) investigated the relationship between depressive symptoms and dry eye disease (DED). Subjects were evaluated for DED using the Symptom Burden Tool and the Ocular Surface Disease Index (OSDI). Depression was evaluated using the Beck Depression Index (BDI). Regression analysis revealed a linear association between the degree of DED and depression and offered further evidence of the association between DED and psychologic disorders, specifically depression.

It would be logical to assume that individuals who have more severe dry eye symptoms might be more prone to psychologic issues such as depression and anxiety. Szakáts et al (2016) investigated the association between health-related and general anxiety and symptoms of depression versus dry eye-associated signs and symptoms. Using objective parameters only, 85% of symptomatic subjects and 82% of asymptomatic subjects were diagnosed with DED. Psychologic scores were significantly worse in symptomatic subjects, both in those who had objective findings and in those who did not. The authors concluded that anxiety and depression in DED may explain the lack of correlation between DED signs and symptoms.

We have broadened our understanding of, and interest in, the nature and impact of aqueous deficient versus evaporative DED. Tong et al (2013) investigated the relationship of these subtypes with regard to anxiety and depression. Using the Hospital Anxiety and Depression Scale (HADS) and the Center for Epidemiologic Studies Depression Scale (CESD), they screened subjects for depression, after which the same subjects underwent a series of objective and subjective tests for DED. Patients were classified as evaporative, aqueous deficient, or mixed DED. Abnormal CESD scores were associated with symptomatic aqueous deficient and evaporative DED. HADS anxiety scores were associated with symptomatic evaporative and mixed DED, but HADS depression scores were not associated with any dry eye subtypes. Their study reinforces the association of DED with psychologic disorders.

Understand the Impact

I am very fortunate; my vision is back, and my depression is pretty much behind me. But for many of our patients, DED is a life-long condition with many implications, including psychologic disorders. In many cases, the anti-anxiety and anti-depression medications that patients take make their ocular surface disease worse. As healthcare providers, we need to be aware of all implications of DED on their quality of life, including mental wellness. CLS

For references, please visit www.clspectrum.com/references and click on document #275.