SoutHeRn CALiFoRniA CoLLege oF optoMetRy. ABSTRACT. Purpose: To assess if certain types of Acquired Brain Injuries (ABI) relate to the degree of Dry Eye ...
Severity Levels of Dry Eye Syndrome in Patients with Various Types of Acquired Brain Injury Lynn A. Lowell, O.D., F.A.A.O., F.C.O.V.D., Milton M. Hom, O.D., F.A.A.O., Dip. CCLRT Southern California College of Optometry
Methods: Forty-one patients with ABI and DES were surveyed using a validated questionnaire for dry eyes, the Ocular Surface Disease Index© (OSDI©). The scoring range of the OSDI© is from 0 (asymptomatic) to 100 (extremely symptomatic). A score of 13 and greater is considered symptomatic for DES. Furthermore, the scoring range is divided into degrees of severity: mild (13-22), moderate (23-32), and severe (33100). The categories of ABI include: Cerebral Vascular Accident (CVA), Diffuse Axonal Injury (DAI), Traumatic Brain Injury (TBI), and Miscellaneous Causes. Results: The mean OSDI© score for all 41 patients was 45.46 (range of 13.64 – 87.5) with a standard deviation (SD) of ± 18.61. This sample included 21 males and 20 females with an average age of 52.71 years old. Patients diagnosed with CVA (n=9) were the most symptomatic with an overall score of 48.85 (SD ± 17.83), followed by patients with TBI (n=19) at 45.89 (SD ± 20.90), then DAI (n=10) at 45.41 (SD ± 16.97), and lastly patients with ABI from miscellaneous causes (n=3) at 32.64 (SD ± 11.47). Additionally patients with CVA had the highest percentage of severe DES (8/9) at 88.89%, followed by DAI (8/10) at 80%, then TBI (15/19) at 78.95%, and lastly ABI from miscellaneous causes (1/3) at 33.33%. Conclusions: In our pilot study, patients with various types of ABI were highly symptomatic for DES with an overall mean OSDI© score in the severe range. Specifically patients who had CVAs were the most symptomatic for DES, followed by TBI, DAI, and ABI from miscellaneous causes. This information may suggest that further research is indicated to identify the causative mechanism for DES in various types of ABIs.
Results
100.00% 90.00%
• 41 patients with Acquired Brain Injury and Dry Eye Syndrome were surveyed
80.00%
• Using the validated questionnaire for dry eyes: Ocular Surface Disease Index© (OSDI©); self-reported dryness symptoms were collected1-2
N=4 N=5 N = Number of Patients
• Scoring was on an overall point scale of 0 (zero) to 100 • The OSDI© includes 12 questions and scores are tabulated based on a point system corresponding to the frequency of the patient’s symptoms: (4) All of the time (3) Most of the time (2) Half of the time (1) Some of the time (0) None of the time
Dryness Severity Levels Designated by the OSDI© Survey
Results • 41 patients: 21 Males, 20 Females • All examined and surveyed from December 2010 to September 2011 • Mean Age: 52.71 y.o., Age Range: 15-88 y.o.
Overall OSDI© Findings
Previous research has shown that patients with Acquired Brain Injuries (ABI) are oftentimes symptomatic for Dry Eye Syndrome (DES).3-5
OSDI© scores ≥ 13 is symptomatic for DES
•
Distribution of Severity Levels of DES within Each ABI Category Number of Patients within Each Designated Severity Level Mild DES
Moderate DES
Severe DES
Number of Total Patients
Overall
4
5
32
41
Overall Average OSDI© Score 45.46
CVA
0
1
8
9
48.85
TBI
3
1
15
19
45.89
DAI
1
1
8
10
45.41
Other
0
2
1
3
32.64
These results spurred further investigation upon the severity of the DES reported and any correlation between the type of ABI incurred and the severity level of the dry eye symptomatology.
Percentage of Severe DES
N = 41 Mean overall OSDI© score of 45.46 (range of 13.64 – 87.5) Standard deviation of ± 18.61
ABI Categories
Prior to this study, we surveyed 50 patients diagnosed with visual deficits from ABI.4 Of that sampling, 82% were symptomatic for DES using the OSDI© validated survey.1-2
Percentage of Severe DES within Each ABI Category
Degrees of severity: mild (13-22), moderate (23-32), and severe (33-100)
Category of ABI CVA TBI DAI Other
30.00%
33.33%
CVA
TBI
DAI
Other
Conclusion
Table 1: Number of Patients within each ABI category and each DES severity level
Background and Introduction
40.00%
Figure 3: Percentage of Severe DES within Each Acquired Brain Injury Category
•
Category of ABI
50.00%
Acquired Brain Injury Category
Categories of Acquired Brain Injuries (ABI)
Figure 1: List of Visual Deficit Categories
60.00%
0.00%
Total Number of Patients Surveyed = 41
Cerebral Vascu lar Acc ident (CVA) Diffu se Ax onal Injury (DAI) Traum atic Brain Injury (TBI) Mis cellaneous Causes
80%
10.00%
Figure 2: Overall Number of Patients within Each Level of Dryness Designated by the OSDI© Survey
• • • •
78.95%
20.00%
Mild Moderate Severe
N=32
88.89%
70.00%
Overall Distribution of Severity Levels of DES in Patients with ABI
Percentage
Purpose: To assess if certain types of Acquired Brain Injuries (ABI) relate to the degree of Dry Eye Syndrome (DES) experienced in this patient population.
Methods
ABI Categories
Abstract
Percentage of Severe DES within Each ABI Category
Number of Patients
Percentage
8/9 15/19 8/10 1/3
88.89% 78.95% 80% 33.33%
Table 2: Percentage of Severe DES within Each Acquired Brain Injury Category
• • •
The mean OSDI© score for the 41 patients previously diagnosed with ABI that participated in this survey was 45.46. This score falls within the severe range according to the designated OSDI© severity levels. Patients diagnosed with having a Cerebral Vascular Accident (CVA) / Stroke were the most symptomatic for DES with an average score of 48.85. Additionally CVA/Stroke had the highest percentage of patients symptomatic for DES at 88.89%. Based on this data, a dry eye work-up may be considered for patients with Acquired Brain Injuries. These results also suggest that further investigation of causative linkages between ABI and DES is indicated. As seen in our previous study, 82% of patients with incurred functional visual deficits from an ABI had DES. Possible contributing factors may include secondary effects of these visual deficits such as in binocular vision disorder which can lead to decreased blinking rates to minimize double vision. This decreased blink rate may lead to corneal exposure and dryness.
References 1. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000 May;118(5):615-21. 2. Kimberly L. Miller, PhD; John G. Walt, MBA; David R. Mink, MS; Sacha Satram-Hoang, PhD; Steven E. Wilson, MD; Henry D. Perry, MD; Penny A. Asbell, MD, MBA; Stephen C. Pflugfelder, MD. Minimal Clinically Important Difference for the Ocular Surface Disease Index Arch Ophthalmol. 2010;128(1):94-101. 3. L. Lowell, O.D., A.H. Cohen, O.D., N. Kapoor, O.D., M.S. Optometric management of visual sequelae of frontal lobe-related traumatic brain injury. J Behav Optom 2010;21:3-11. 4. L. Lowell O.D., M. Hom, O.D. Symptomatic Dry Eye in Patients with Acquired Brain Injury. Scientific Poster. Association for Research in Vision and Ophthalmology (ARVO). Ft. Lauderdale, FL. May 2012. 5. D. Rutner, O.D., M.S., N. Kapoor, O.D., M.S., K. Ciuffreda, O.D., Ph. D., et al. Frequency of Occurrence and Treatment of Ocular Disease in Symptomatic Individuals with Acquired Brain Injury. A Clinical Management Perspective. J Behav Optom 2007; 18:31-36.
