Figure 1: Daily disposables may have a role in overcoming a number of lifestyle challenges
Much of the advice we offer our patients is focused on meeting the challenges of everyday life. ‘Take regular breaks when using your computer’, or ‘try not to wear so much eye make-up when you plan on wearing your contact lenses’, may seem like common sense.
More recently, you may have veered into newer areas of advice, such as ‘try spending more time outdoors’ or ‘have you thought about reducing the amount of saturated fat in your diet?’ Whether common sense or not, the key question has always to be: is there any evidence to support our advice?
Let us consider a classic example. Most of us recite almost mantra-like what has become widely known as the 20-20-20 rule. The catchy name, with its nod to 20/20 vision, and an obvious grounding in truth based on acres of research showing that prolonged staring has a negative impact on the tear film have made this ‘rule’ popular and an easy to remember way of changing a behaviour.
Readers may have noted it being used by UK ophthalmologists in a recent report on minimising the stress of high-volume surgery. However, a paucity of any underlying evidence means it has no more validity as a quantifiable rule of viewing timing and strategy than might ‘eat more vegetables’ be as a diet plan.
So, when the Tear Film and Ocular Surface Society (TFOS) announced recently the publication of a systematic review of research into the various influences of modern living upon the health of the ocular surface and tear films, we all need to take note.
Just as the TFOS DEWS2 report is now the go-to authority in contact lens an anterior eye clinic when dealing with the impact of dry eye, the new TFOS Lifestyle reports should have a similar impact on what advice we offer regarding lifestyle and the maintenance of a healthy, asymptomatic ocular surface.
The aim of this article is to highlight the key points raised by the publications.
TFOS Lifestyle Epidemic Reports
The TFOS was founded as a non-profit organisation ‘to facilitate forward momentum in ophthalmological research’. As such, it has employed a host of researchers and academics to analyse published research to help guide current clinical practice and to help focus future research in the areas of external and anterior eye health.
The first workshops dealt with dry eye disease and resulted in the publication of the original Dry Eye Workshop (DEWS) and a subsequent DEWS2 series of papers. The publications have helped to define the condition of dry eye disease, something that was previously somewhat nebulous, and also to promote a systematic approach to both its assessment and management, all based on an accurate analysis of the published evidence base.
This latest TFOS Workshop has worked under the overarching title of ‘A Lifestyle Epidemic: Ocular Surface Disease.’ A steering committee was formed, under the leadership of the Workshop Chair Jennifer Craig, Vice Chair Monica Alves, and Organiser David Sullivan, to plan and execute this TFOS Lifestyle Workshop and comprised of leading authorities from around the world, including our own Professor James Wolfssohn of Aston University.
They then formed a group of sub-committees to, in their words, ‘increase awareness of the potential impacts of lifestyle choices on ocular surface health’ and to ‘achieve a consensus concerning the relationship(s) between lifestyle factors and their impact on ocular surface disease.’
Under the steering committee, eight topics were assigned to sub-committees as listed in table 1. In addition, a further three sub-committees were set up; two for addressing links with industry and improving public awareness of the findings and a third, novel one, which was tasked with looking at the quality of the evidence gathering in existing research and to help support better quality research for the future.
Table 1: Topic area subcommittees of the TFOS Lifestyle Workshop
Because of the widespread reach of some topic themes, for example the impact of environmental conditions, each sub-committee were given a single question upon which to focus, for example ‘what is the association between outdoor environment pollution and dry eye disease symptoms and/or signs in humans?’ This has helped to narrow down the searches and to allow some specific outcomes to be published.
The remainder of this short review will focus on the first three of these and a comprehensive review of each topic will be published in Optician later in the year.
Contact Lenses
The stated aim of this report was to look at the impact of a wide variety of factors, with the aim of providing a holistic map of:
- Factors that impact the choice of whether to wear contact lenses
- Factors that impact the success or otherwise of those who elect to wear contact lenses
The report had a broad brief and covered areas such as the reasons for contact lens wear, choice of contact lens, reasons for drop-out and the always important topic of compliance. The report includes data obtained during the recent pandemic, which had introduced us to concepts such as mask-associated dry eye. There is also mention of the nature of the market, such as the influence of online and unregulated sales of contact lenses.
However, the main question to be addressed was: What lifestyle factors are associated with people dropping out of contact lens wear?
The main conclusion: more and better research is needed. Or, as the report puts it: ‘Examination of the literature resulted in an appreciation of the fact that several areas of study lack high quality evidence and would benefit from further exploration.’
Considering lifestyle choices specifically, the report notes that ‘lifestyle choices can impact the success and safety of contact lens wear. The avoidance of risky behaviours, such as sleeping in lenses, failing to comply with instructions from the eye care providers, failing to attend for regular aftercare visits, purchasing contact lenses and solutions from unregulated vendors, wearing or sharing ‘party’ lenses, and using tobacco, alcohol or recreational drugs, can all increase the risk of adverse consequences.’ It is good to have our suspicions confirmed.
With respect to contact lens dropout: ‘Much further work is required to acquire high quality data that will provide information on the lifestyle factors that can result in the discontinuation of lens wear, which continues to occur in approximately 25% of wearers over a two to three-year period.’
Of particular interest regarding drop-out, the report notes that randomised controlled trials (RCTs) might not be the best approach to ascertain the causes for drop-out, and researchers may wish to consider more use of ‘surveys embedded within clinical practices or longitudinal web-based surveys.’
Finally, the report notes that the trend towards daily disposables has been a positive one and further research should confirm that this modality has helped minimise the negative impacts of lifestyle on ocular health (figure 1).
Cosmetics
For a long time, anecdotal evidence for the adverse impact of cosmetics has abounded. Of all the reports, I found the one looking at the impact of cosmetics on the ocular surface on most interesting, not least because such a large part of it was a detailed discussion of the history of cosmetic use from 3000BCE to the modern day, the evolution of cosmetic materials, and of the many influences upon cosmetic use, such as gender, age and culture. As with history in general, this highlights the role of anecdotal reporting, of course.
To pin down the analysis, the question focused upon was: Is the use of eyelash growth serums associated with symptoms and/or signs of ocular surface disease?
Concerns have been raised about the potential toxicity of many components of cosmetics used around the eyes and this report offers a useful and comprehensive coverage of this topic.
As the report confirms, ‘a number of the ingredients in these products may act as allergens, carcinogens, endocrine disruptors, immunosuppressants, irritants, mutagens, toxins and/or tumour promoters, and may damage the ocular surface and adnexa.’
There is also a note that the many trends towards such cosmetic procedures as eyelash lengthening, botulinum toxin injection, false eyelashes and adhesives use and many others ‘may also be associated with adverse ocular events.’ We should all pay attention to this, methinks.
With regard to the specific question asked, it would seem that, again, more research is required. ‘Using valid and reliable measurement tools, there is currently an absence of evidence based on high-quality RCTs examining the signs or symptoms of ocular surface disease associated with the use of eyelash growth products. Future trials are needed to better clarify the effects of eyelash growth products on the signs and symptoms of ocular surface disease.’
Some specific components of cosmetics are highlighted that may have very significant adverse effects on the ocular surface and/or adnexa. These are listed in table 2.
Table 2: Ten eye makeup ingredients that may have very significant adverse effects on the ocular surface and/or adnexa
The authors call for, alongside future research, a tighter regulation of the supply of potentially harmful products for cosmetic use. ‘For the future, the authors support the recommendation that ocular cosmetics sold commercially list concentrations of all chemical components, as well as provide information about the product’s function, toxicity, indications, contraindications, durability and expiration date.’ Here, here.
Digital Environment
One area we all know has had a major impact on the health of our eyes is the advent of the digital era, with many hours spent staring at digital screens. This has been a major contributor towards ocular surface irritation and has led to the introduction of the term ‘digital eye strain’, defined as ‘the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing.’ The somewhat vague definition has led to some quotes of the prevalence of digital eyestrain as being as high as 97%.
As the report covers, much of the problem of ‘ocular surface disease exacerbation’ are mainly related to ‘reduced blink rate and completeness, partial/uncorrected refractive error and/or underlying binocular vision anomalies, together with the cognitive demand of the task and differences in position, size, brightness and glare compared to an equivalent non-digital task.’
When it comes to interventions, however, the report states that none are ‘well established’, while emphasising the need for accurate refraction correction to be worn and ‘improving blinking, optimising the work environment and encouraging regular breaks may help.’
There is an excellent graphic included to offer an overview of the appropriate strategy for the management of digital eye strain, upon which figure 3 is based.
Figure 3: Digital eye strain management
Of note, the report states: ‘Based on current, best evidence, blue-light blocking interventions do not appear to be an effective management strategy.’
The over-riding conclusion is again, the need for more research. However, when focusing on the specific question ‘which ocular surface disease management approaches reduce symptoms associated with digital device use?’ there is some evidence showing promise for some approaches.
‘More and larger clinical trials are needed to assess artificial tear effectiveness for relieving digital eye strain, particularly comparing different constituents; a systematic review within the report identified use of secretagogues and warm compress/humidity goggles/ambient humidifiers as promising strategies, along with nutritional supplementation, such as omega-3 fatty acid supplementation and berry extracts.’
Other Key Findings
In the section on lifestyle, one finding quoted is: ‘With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and dry eye disease symptoms.’
In the section on nutrition, none of the currently published studies looking at fasting and food restriction were considered to be of high enough quality to draw any significant conclusions. Again, more research needed.
The section on societal challenges includes the conclusion: ‘While the impact of age, race and biological factors on many ocular surface diseases are well established, the effects of sex may be confounded by other social or gender constructs including access to health care, employment, poverty and education.’
- The original papers are available for download at www.sciencedirect.com/journal/the-ocular-surface/special-issue/10LJDHN7GSM
- A series of CPD features offering an overview of each of the TFOS Lifestyle papers will be launched in Optician in the autumn.