Identification of Risk Factors for Dry Eye Syndrome in Productive Age

Eva Zerlina Widyawati ( evazerlina@gmail.com )

SUMMARY

Background: Dry Eye Syndrome (SMK) is a multifactorial disease on the surface of the eye. It is

characterized by loss of tear film homeostasis and is accompanied by ocular symptoms in which the

tear film is unstable with hyperosmolarity, inflammation and damage to the ocular surface, and

neurosensory abnormalities. Large epidemiological studies have shown that the prevalence of SMK

in women and men increases every 5 years, and the prevalence rate of women is higher than that of

men. SMK will continue to be one of the main reasons for eye treatment. Symptoms resulting from

ocular discomfort and visual blurring can have a significant impact on quality of life and work

productivity.

Methods: The research method uses international and national online databases (PubMed, Google

Scholars, Proquest, and ScienceDirect) in the last 5 years to search for articles in this systematic

review. Journal load topic various factor risk happening Dry Eye Syndrome on age productive .

Results: From 33 journals stated that smoking, activity outdoor , Visual Display Terminal , glitches

affect , use lens contact , allergy eyes are a thing which play a role in the risk factors for Dry Eye

Syndrome in productive age.

Discussion: Smoking , activity outdoor , allergy eyes , distraction affect , use Visual Display

Terminal becomes factor risk Dry Eye Syndrome

Conclusion: . Smoking, use of Visual Display Terminals , usage lens contact , affective disorders,

eye allergies, outdoor activities become factor the risk of Dry Eye Syndrome at reproductive age .

Keywords: (3-8 words)

Dry Eye Syndrome, Dry Eye Disease, Risk Factor, Screen Time
INTRODUCTION years, and the prevalence rate of women is

Dry Eye Syndrome (SMK) is a higher than that of men. With the aging

multifactorial disease on the surface of the population and increasing life expectancy,

eye. It is characterized by loss of tear film VHS will continue to be one of the main

homeostasis and is accompanied by ocular reasons for eye treatment. Therefore, a better

symptoms in which the tear film is unstable understanding of age-related SMK and

with hyperosmolarity, inflammation and treatment for this special population is

damage to the ocular surface, and important. Previous epidemiological evidence

neurosensory abnormalities. It plays an has shown that the overall prevalence of SMK

etiological role. Symptoms of SMK include is between 5% - 87.5% in the general

dry eyes, eye pain, burning sensation, vision population worldwide. In mainland China, the

problems, eye fatigue, sensitivity to light and prevalence rate of the elderly over 60 is

itchy eyes. (1) markedly higher, at around 34.4%, while the

The prevalence of SMK is high among comprehensive prevalence rate is 17%. It is

eye conditions, and varies between 14.6% and reported that the proportion of elderly

30% depending on the diagnostic method regional population in Australia, Taiwan,

used and population characteristics. A recent South Korea and Japan are respectively

systematic review revealed that one in five 57.5%, 33.7%, 33.2% and 21.6% (3,4) .

Asians experience SMK. Therefore, SMK has SMK is a disease of the tears and the

been considered as a disease of multifactorial surface of the eye that can cause discomfort

etiology , and is correlated with the presence and visual disturbances, with potential

of certain systemic comorbidities . (2) . damage to the surface of the eye. These

Large epidemiological studies have symptoms can affect quality of life and

shown that after the age of 50, the prevalence activities of daily living (5) .

of SMK in women and men increases every 5

 Symptoms resulting from ocular to determine the risk factors that influence the

discomfort and visual blurring can have a occurrence of Dry Eye Syndrome.

significant impact on quality of life and work

RESULTS
productivity (6) .
Through the process of reviewing and

selecting articles, researchers obtained

MATERIALS AND METHODS
journals that met the inclusion and exclusion
Strategy and Journal Search
criteria and were relevant to this study. All
The research method uses international and
articles used are articles in English. Of all the
national online databases (PubMed, Google
journals we reviewed, most showed that the
Scholars, Proquest, and ScienceDirect) in the
risk factors for Dry Eye Syndrome in
last 5 years to search for articles in this
Productive Age include smoking, outdoor
systematic review. The keywords used are
activities, eye allergies, affective disorders,
“Dry Eye Syndrome”, “Dry Eye Disease”,
and contact lens use. This review consists of 3
“Risk factor” “Screen Time”. All journals
cases control , 5 Meta- analysis , 7 cross
used are taken from documents published
sectional ,3 Studies epidemiology , 8
2018-2023.
Observational Studies, 5 Systematic review.
Inclusion Criteria and Exclusion Criteria
of 3 3 journals stated that habits such as
The inclusion criteria used were: 1) The
smoking, are behaviors that play a role in the
articles included in this study were research
risk factors for Dry Eye Syndrome at
articles, literature reviews in quantitative,
productive age. Only 2 out of 3 3 journals
qualitative or mixed methods research, 2)
stated that there was no relationship between
Articles were written in English. While the
smoking and the incidence of dry eye
exclusion criteria used were: 1) Articles or
syndrome. In 14 journals it was discussed that
research journals without full text and
the biggest risk factor for Dry Eye Syndrome
abstracts, anonymous reports, duplicates, or
in productive age was the length of Visual
editorial reports. The purpose of this study is
Display Time , while the effect of using
contact lenses was discussed in 13 journals. 51.3% are exposed to cigarette smoke at work

Factors of eye allergy are mentioned in 12 (7) .

journals. Outdoor activities are mentioned in In research conducted by Bala et al . In 19

7 journals. patients who had a history of smoking, 11 of

them had SMK which showed a percentage of

DISCUSSION
This systematic review consists of a total of 3 57.89%. (8) . Cross study results sectional on

3 journals that contain health issues regarding Alexandra's research et al . showed that being

the factors of Dry Eye Syndrome in a passive smoker can increase the

productive age such as smoking, outdoor susceptibility to Dry Eye Syndrome.

activities, affective disorders, use of visual Regression analysis showed a significant

display terminals , use of contact lenses, and relationship between the presence of dry eye

eye allergies. syndrome and passive smoking (OR = 1.13,

95% CI 1.04-1.64, p<0.001) (9) .

1. Smoke
Smoking was not found to be a risk factor
Smoking is still considered a normal
among respondents from Luna's study et al .
behavior that is a way of life for the majority
(OR 1.4, 95% CI 0.89-2.53, p -value= 0.642).
of Indonesian people. According to the 2011
In addition, studies in Singapore and Palestine
GATS survey, the prevalence of smokers in
found no statistically significant correlation
Indonesia ranks second in the world, with the
between smoking and SMK. However, one
highest number of active smokers with a
Turkish study involving female smokers and a
prevalence of 67% for men and 2.7% for
meta-analysis conducted over the last ten
women or 34.8% of the population (about
years in the general population indicated that
59.9 million people). ) and 85.4% of people
smoking may be a risk factor. Study
who are exposed to cigarette smoke in public
participants spent most of their time indoors
places, namely restaurants, 78.4% are
and therefore had low exposure to
exposed to cigarette smoke at home and
secondhand smoke, which may explain the
absence of an association between smoking was found that the use of VDT for more

and dry eyes in this study. (13) . than four hours per day is a major risk in

Several studies suggest that not only is developing SMK with the average

smoking a risk factor in itself, but exposure to duration of using VDT for those who

environmental fumes can also develop dry experience SMK is 7.28 ± 2 .04 hours.

eye symptoms (14) . Smoking increases a (OR=1.58 (1.41-1.79, p<0.001)) (16) .

person's susceptibility to dry eyes by reducing Employees who did not rest their eyes

TBUT ( Tear Break Up Time ). Sherry et al. while using the VDT every two hours

(2020) reported that there is a relationship were 1.22 times more likely to experience

between SMK and smoking (13) . severe dry eye symptoms than those who

Cigarette smoke is known to irritate the rested their eyes. Employees who use a

eyes and make dry eyes worse. People who VDT without a screen filter are 1.90 times

smoke are almost twice as likely to have dry more likely to experience severe dry eye

eyes (15) . Smoking has a detrimental effect symptoms (16) .

on most anterior eye diseases (12) . Cigarette A VDT brightness of less than 400

smoke can damage the fatty precorneal tear Lux is 2.27 times more likely to

film by the process of fatty peroxidase which experience severe dry eye symptoms

causes dry eye syndrome and damage to the compared to the standard brightness range

ocular surface (7) . (400-500 Lux). In this study, 54 VDT

2. Use of Visual Display Terminals users (56.16%) who worked on a

The risk factors that were found to be computer screen for 5-7 hours per day had

significantly associated (p<0.05) with severe dry eye symptoms.

SMK were more than 3.71 hours of VDT The use of VDT for 5-7 hours per day

( Visual Display Terminal ) use is associated with dry eye symptoms with

(p<0.001). In a study conducted by Rossi a statistically significant value (p value =

GC et al., on professional VDT users, it 0.01). These results are in agreement with
the study by Rossi G. et al. who found province of Ubon Ratchathani, Thailand,

that VDT use for more than 4 hours per which revealed that 72.9% of VDT users

day was a risk factor for dry eyes (17) . have table brightness of less than 400

qian et al . found that only 7 VDT Lux. In addition, it was also found that 25

users (6.7%) had standard illuminated VDT users (24%) had a desk brightness of

desks. However, severe dry eye symptoms less than 150 Lux, which is the minimum

were found in 71.4% of VDT users whose lighting intensity in an office or computer

desks were within the standard brightness room. In a dimly lit environment, the

range. This can be related to several other pupil diameter widens due to contraction

factors that can influence dry eye of the iris expanding muscle (17) .

symptoms, including 1) reflected light, When using a VDT, the pupil

such as light coming from a window or constricts from the action of the circular

door that bounces off a computer screen iris sphincter muscle (18) . The

and then is reflected back to the eye; 2) simultaneous action of these two iris

directional light, such as direct light from muscles causes more effort to stare at the

a computer screen into the eye; 3) low screen trying to adjust the brightness of

temperature and low humidity in the the image and the light produced by the

workplace which can lead to higher tear computer screen. This visual effort causes

evaporation. All of the above factors can a decrease in the frequency of blinking

also be contributing factors in the and an increase in eye strain (asthenopia),

occurrence of dry eye symptoms. For resulting in faster evaporation of tears

work with less than standard light from the surface of the eye and leading to

intensity, there are 82 VDT users (78.8%) various dry eye symptoms . (19)

whose desks are illuminated at less than Dry eye symptoms in VDT users can

400 Lux. These results are consistent with be caused by constant focusing on the

the results of another study in the monitor which can lead to decreased blink
frequency or incomplete reflex blinking, living in urban areas (OR 1.092; 95% CI

resulting in increased tear evaporation and 1.005- 1.187). (24) A similar prevalence

tear film instability (17) of dry eye syndrome symptoms was

3. Outdoor Activities reported among the Thai population by

Multivariate logistic regression Wiwatanadate et al . Another study

analysis showed a significant association conducted in Korea strongly confirmed

between the presence of dry eye syndrome the correlation between high levels of

and exposure to outdoor air pollution (OR ozone and nitrogen dioxide and dry eye

= 1.92, 95% CI 1.47-2.52, p <0.001) and syndrome. Torricelli , on the other hand et

passive smoking (OR = 1.13 , 95% CI al . showed a relationship between high

1.04-1.64, p<0.001) (23) . levels of PM10 in large metropolitan areas

Air pollution is a mixture of a large with decreased TBUT and conjunctival

number of pollutants and sometimes it is goblet cell density (9) .

very difficult to determine the individual Working outdoors and being exposed

impact of each pollutant on the eye. There to the outside environment were

is substantial evidence that chronic significant risk factors (p = 0.002).

exposure to ambient air pollution is (Hannan 2022). Air pollution, as reflected

associated with subclinical changes in the by NO2 and PM10, is associated with

ocular surface and tear film in people more dry eye cases (12) .

living in urban areas. Different pollutants 4. Contact lens

affect the eyes in different ways. A study In Zahra's research et al . explained

from South Korea showed a positive that the use of contact lenses has a 2.14

relationship between SO2 concentration times the risk of developing SMK

and diagnosis of dry eye syndrome (OR compared to non-contact lens wearers

1.092; 95% CI 1.011-1.179) and (OR = 2.14 (95% CI = 1.65, 2.77)) (25) .

symptoms of dry eye syndrome in people

 In the study of Yang et al . explained the severity of ocular surface disease, as

that the use of contact lenses has a 1.59- suggested by a comprehensive study

fold risk of developing SMK compared to published by Hu et al. who reported a

non-contact lens wearers (OR= 1.59 95% BUT of 3.1 ± 1.6 seconds vs. 4.5 ± 1.0

CI 1.240 – 2.04). Prevalence of SMK in seconds vs. 11.4 ± 1.0 seconds (P < 0.01),

contact lens users aged between 20-30 in the AKC, VKC and healthy control

years. This is in line with Patakorn's groups, respectively. (28)

research, 2021 which states that More recent studies, comparing

respondents who use contact lenses are children with SAC, PAC, and even

1.62 times at risk of experiencing SMK allergic rhinitis with healthy peers, show

than those who are not users (2) . that these conditions also affect the

Contact lenses decrease goblet cell stability of the tear film . Significantly,

density and result in conjunctival several studies of tear film stability in

metaplasia, which can disrupt the tear film intermittent forms of ocular allergy

(26) . People who wear contact lenses are reported that VKC patients appeared to

at an increased risk of infectious keratitis. exhibit shorter BUT even in the quiescent

Wearing lenses should be stopped phases of the disease, while SAC patients

immediately if a person is developing an did not experience decreased tear film

eye infection (27) . stability outside of the pollen season. .

5. Eye Allergies (22)

An increasing number of articles The results of the logistic regression

report an association between eye analysis of Wan et al . showed that

allergies and decreased tear film break-up students who have allergies are more

time (BUT). This phenomenon is more likely to have SMK (p = 0.049). Allergic

pronounced in allergic kerato- conjunctivitis and other ocular surface

conjunctivitis, and appears to be related to diseases may be associated with

symptoms similar to those of MS, but in that lines the eye and the inside of the

some studies, they are considered as eyelids (30) . Vigorous and prolonged eye

separate clinical entities. There is rubbing can lead to thinning and loss of

evidence that allergic diseases, such as corneal rigidity related to mechanical

vernal and atopic keratoconjunctivitis and damage mechanisms. (33)

allergic conjunctivitis, are associated with Several imaging studies evaluate the

a higher risk of MS (29) . meibomian gland in different forms of

In Acimovic's research et al . it was ocular allergy, including AKC, VKC, and

found that people with certain allergies PAC. They demonstrated morphological

were at risk of 1.6 times suffering from changes, possibly related partly to

SMK than those who did not (OR=1.637 inflammation of the ocular surface and

95% CI for OR 1.00–2.67 P-value 0.049) partly to persistent mechanical stress on

(1) . the tarsal tissues from eye rubbing. The

Those with a history of conjunctival or functional implications of these

eyelid infection had a significantly higher morphological changes have been

rate of MS than those without a history of suggested, but need further investigation.

conjunctival or eyelid infection (p < Only one study, published more than 10

0.001) (31.9% vs 11.7%). In addition, years ago by Suzuki et al. evaluate

those with a history of corneal changes in the lipid layer of the tear film

abrasion/corrosion/ulcer had a in allergic ocular. This study

significantly higher rate of SMK than demonstrated increased lipid layer

those without such history (p < 0.001) thickness in patients with SAC and

(30.1% vs 16%) (19) . reported a surprising negative correlation

Eye allergies occur when a person is between lipid layer thickness and BUT.

allergic to certain substances that irritate (22)

the conjunctiva, which is the thin lining

 The impact of ocular allergy on disorders may result in more severe CMS

secreted and membrane-associated mucins due to tear film dysfunction and changes

has been studied in greater depth, at least observed in ophthalmological

in its severe form. Preclinical studies in examinations. The relationship between

mouse models demonstrated that SMK and stress levels can be caused by

histamine, leukotrienes, and increased production of interleukin-1, -2, -

prostaglandins directly stimulate goblet 6, -8, and TNF-alfa. These factors lead to

cell secretion, whereas inflammatory inflammation of the ocular surface as well

cytokines such as IL-13, TNFa, and IFNg as intensification of negative emotional

have opposing effects on the regulation of states. In this study, it was found that

secretion, proliferation, and apoptosis of depression and other mental disorders

these cells. Several in-vivo studies from were significantly associated with a

Keio University reported reduced higher risk for DES (OSDI: respectively,

MUC5AC in patients with AKC and p < 0.001 and p = 0.019, DEQ-5:

VKC, especially in eyes with protective respectively, p = 0.005 and p = 0.127,

corneal ulcers. This reduced tear which is close to the level of

concentration of gel-forming mucin is significance). In addition, the severity of

widely accepted as a feature of all forms DES also increased (OSDI: p < 0.001 and

of DED. (22) p = 0.039, respectively). These results are

6. Affect Disorders in line with previous research on the

SMK can be affected by stress. A relationship between SMK and mental

correlation between perceived stress disorders (including depression, anxiety,

levels and dry eye symptoms was found in PTSD, dementia, bipolar disorder, and

the multifactorial analysis of this study. It neurotic disorders). However, psychiatric

was explained that stress and psychiatric symptoms such as depression or anxiety

illness such as depression or mood are only associated with subjective

symptoms of SMK and not objective and anxiolytics. One study reported that

symptoms. It should also be noted that proinflammatory cytokines such as

dysregulation of serotonin levels in interleukin-1, interleukin-6, and tumor

depression can cause dry eyes through necrosis factor-a can cause inflammation

disruption of the ocular surface because of the ocular surface in dry eye disease,

serotonin receptors are present in the affect neurotransmission and generate or

conjunctival epithelium and Meibomian enhance negative moods. (24) .

glands. (21) . The potential role of depression and

Patients who use anxiolytic drugs are PTSD may be explained by dysregulation

5.7 times more likely to suffer from SMK. of serotonin-related neuropeptides in

Anxiety was identified as a potential human tears and serotonin receptors in the

predictor of SMK (p = 0.016) in the human conjunctiva. depression (OR: 1.83;

univariate analysis, but was not P<0.001) (5) .

independently associated with SMK in the CONCLUSION

multivariate analysis. Therefore, the Smoking, use of Visual Display

relationship between SMK and anxiety Terminal , affective disorders, eye

may occur as a result of the relationship allergies, outdoor activities become factor

between SMK and anxiolytics (31) . the risk of Dry Eye Syndrome in women

Suicidal ideation showed a 1.4 times of childbearing age . loss of tear film

greater risk than those without it (aOR, homeostasis And accompanied with

1.414; 95% CI, 1.070-1.870). Someone symptom ocular where the tear film No

with suicidal ideation may have other stable with hyperosmolarity ,

psychiatric problems, such as stress, inflammation And damage surface

depression, and insomnia, dry eye ocular , and abnormality neurosensory .

symptoms can be related to the use of Overall control of various factors can

psychiatric drugs such as antidepressants

 reduce the risk of Dry Eye Syndrome in
women of reproductive age.
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