Ethnicity & Dry Eye Disease

Ethnicity & Dry Eye Disease

November 13, 2021

Several factors play a role in the risk of developing eye diseases. Some are controllable, such as smoking and UV exposure, but other factors are out of our control, such as age. Ancestry can also affect your chances of developing some eye conditions.

According to the American Academy of Ophthalmology, African-American and Latino-American people are more likely to develop diseases, such as glaucoma, cataracts, and diabetic retinopathy compared to Caucasians. Additionally, Asian-Americans have an increased risk of angle-closure glaucoma.

The findings demonstrate that racial and ethnic minorities present with worse dry eye parameters.

This might be due to disproportionate access to dry eye care, potentially secondary to socioeconomic barriers as well as underappreciation of dry eye among minorities leading to differential treatment by providers.

Asian ethnicity is a mostly consistent dry eye disease (DED) risk factor. Co-located ethnic population studies, reducing potential confounding effects of methodological and environmental heterogeneity, may help explain DED natural history.

Results show earliest disparities detected between Asian and Caucasian populations being higher degrees of incomplete blinking and lid wiper epitheliopathy in pediatric Asian participants, likely associated with anatomically predisposed increased eyelid tension.

Interethnic divergence in meibomian gland dropout in the young adult population follows, while other ocular surface characteristics remain within physiological limits; significant differences in meibomian gland function, tear film stability and osmolarity, DED symptomology and overall disease diagnosis (based on TFOS DEWS II criteria) do not manifest until the middle adult population; and disparities in corneal and conjunctival staining become significant only with older age.

Aqueous tear deficiency appears less likely than evaporative mechanisms to be implicated in the Asian ethnic propensity towards DED development. 

Patients who are members of racial and ethnic minority groups present clinically with worse objective measures of dry eye than patients who do not belong to these groups, according to poster research presented at the annual meeting of the Association for Research in Vision and Ophthalmology.

“Dry eye is a condition that is very prevalent and very expensive to treat,” said David Cui, a medical student at Penn State College of Medicine in Hershey, Pennsylvania, one of the study’s investigators, and a research assistant at Johns Hopkins University School of Medicine in Baltimore, Maryland.

Cui noted that estimates of global prevalence for dry eye range from 5% to 50%, and the disease is a leading cause for patient visits to an eye care clinician.

In the United States, the estimated price tag associated with dry eye disease treatment is $3.8 billion annually, representing a substantial stress on the country’s health care system, said Cui.

Cui noted the need to look at the topic of race, whether it influences access to dry eye care, and whether patients have greater dry eye severity, pointing out that no published literature on disparities regarding race, ethnicity, and dry eye patients exists.

He added that existing literature on dry eye and racial minority groups is limited to patients in Asia and that research demonstrates that these patients have a greater prevalence with potentially increased severity.

The retrospective investigation involved review of electronic health records of patients who were treated at a single center by a single ophthalmologist, Esen Karamursel Akpek, MD, the Bendann Family Professor of Ophthalmology and founder of the Ocular Surface Disease Clinic at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, noted Cui.

Investigators excluded patients whose dry eye was secondary to another ocular surface disease such as mucous membrane pemphigoid, Stevens-Johnson syndrome, atopic keratoconjunctivitis, or graft-vs-host disease.

Cui and fellow investigators divided patients into four categories: Asian, Black, Hispanic or Latino, and White. A total of 465 patients were included: 157 were White, 157 were Black, 85 were Asian, and 66 were Hispanic or Latino.

Most patients (78%) were women, and the gender of patients was equivalent in all cohorts. They used objective dry eye measures such as conjunctival staining, corneal staining, combined ocular surface staining, Schirmer’s test, and tear osmolarity at baseline and at a final visit.

Investigators found that a larger amount of minority patients were without health insurance or were on Medicaid, and that Black and Hispanic patients had a lower estimated median household income compared with White patients.

Another finding that emerged was that fewer minority patients previously received prescription treatments or procedures.

At their baseline visit, patients from minority groups had worse mean conjunctival and corneal staining scores. There were, however, no statistically significant diff erences noted in objective dry eye measures at the final visit for patients with a minimum of 18 months of follow-up.

Cui drew an analogy between the treatment of dry eye disease, often a chronic disease in which the chief symptom is ocular discomfort, and data on the treatment of chronic pain.

“There are a lot of publications that show providers treat people with chronic pain differently based on their race and ethnicity,” he said.

“Patients who are non-White typically will be prescribed less treatment for their pain.” Moreover, Cui pointed out that clinicians are less likely to empathize with non-White patients or validate their pain and suffering.

Because dry eye disease is not a condition that can lead to permanent vision loss if left untreated, clinicians may be routinely undertreating the condition despite it having an adverse impact on quality of life, Cui explained.

Cui and fellow investigators found fewer minority patients received prescription treatments or procedures (White patients, 61.8%, vs minority patients, 30.6%-43.9%, all P ≤ .016).

“Medicaid patients are often of low-income status, making it diffi cult to access care, and these insurances almost never cover dry eye treatments,” he said.

Cui noted the study is limited by the fact that is it retrospective and was conducted at a single center. “Because of that, it is hard to draw causation,” he said. “We can draw correlation.

We see that [minority patients] do have barriers to care such as having lower household income, are more likely to be uninsured or are on Medicaid, and have less than full-time employment.”

Cui said investigators also see that members of these groups receive less care, and present with worse objective dry eye parameters, but the diff erences disappear after adequate treatment and follow-up.

Cui thanked his mentors for their guidance and noted that this study will serve as a foundation for their team for future studies regarding disparities associated with dry eye diagnosis and management.

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