Happy New Year and welcome to the 12th year of Ocular Surface News! We are excited to kick off another great year of sharing insights in the field of ocular surface disease. As always, our mission is to expose our readers to evidence-based practice, spark new thoughts and ideas and provide fresh strategies for managing various ocular surface conditions.

As we know, patients often experience exacerbation of their dry eye symptoms due to lifestyle and environmental factors such as excessive digital device use, drafty work environments, smoking and diet, among others. Assessing these outside contributors can be challenging in a busy practice, but taking the time to identify and address them can be highly impactful on our patients’ quality of life. At Ocular Surface News, we aim to equip our readers with new considerations that inspire innovation in patient management. As I reflect upon our journey since our first issue in 2013, one topic I am surprised we have yet to cover is the relationship between sleep quality and dry eye. Given the growing evidence of the connection between poor sleep patterns and ocular health, it is clear this area warrants greater attention in clinical practice. By exploring this relationship further in this week’s issue, we hope to jumpstart your interest in continuing to uncover and address some of the more-overlooked contributors to dry eye disease.

This year, as always, we remain committed to diving deep into the complexities of ocular surface care. Whether it is uncovering new research, rethinking existing paradigms or sharing practical strategies, we look forward to continuing this journey with you. Thank you for your ongoing readership and support. Here’s to a new year of discovery, growth, and improved patient outcomes!

Amber Gaume Giannoni, OD, FAAO
Editor

Tips to Improve Sleep Quality

Sleep plays a critical role in overall health, and its impact on dry eye disease (DED) is an emerging area of interest for eye care providers. A staggering 40% of American adults get fewer than seven hours of sleep per night—the minimum recommended by the American Academy of Sleep Medicine and the National Sleep Foundation.¹ Additionally, suboptimal sleep is commonly seen in patients with DED. A meta-analysis of 19 studies showed that individuals with DED reported worse sleep quality compared to those without the condition.² The correlation between sleep disorders and DED is multifaceted and involves several potential mechanisms.

One proposed theory links sleep, depression, and DED. Studies show that sleep disorders are associated with depression, which is, in turn, linked to dry eye symptoms. Another explanation focuses on pain, a common symptom of DED. The established relationship between pain and sleep disturbances suggests that the discomfort associated with DED may interfere with restorative sleep. Additionally, nocturnal exposure–such as sleeping with an incomplete lid seal or in a room with a fan–may exacerbate DED symptoms and contribute to poor sleep quality.

To help patients improve their sleep, and in turn, improve dry eye symptoms, consider the following tips:

• Encourage patients to establish a consistent sleep routine by going to bed and waking up at the same time each day. Advise them to limit screen time for at least two hours before bedtime and to monitor their caffeine intake, especially in the afternoon and evening. Creating a sleep-friendly environment is also crucial—recommend a quiet, distraction-free bedroom without devices such as TVs, computers and phones!
• Review the skin care products patients use before bed to check whether these products could irritate the ocular surface and exacerbate dry eye symptoms.
• Address potential nocturnal lagophthalmos or incomplete lid seal, which can lead to overnight tear evaporation. 

By improving their sleep quality, patients can wake up with more hydrated, comfortable eyes, and set the foundation for more successful dry eye management.

References:

1. Jaffee MS. Why are we so sleep deprived, and why does it matter? The Conversation. March 7, 2018. Updated March 3, 2020. Accessed January 2, 2025. https://theconversation.com/why-are-we-so-sleep-deprived-and-why-does-it-matter-91803
2. Merikanto I, Kortesoja L, Benedict C, et al. Evening-types show highest increase of sleep and mental health problems during the COVID-19 pandemic–multinational study on 19,267 adults. Sleep. 2022 Feb;45(2):zsab216. doi:10.1093/sleep/zsab216. 

Addressing Possible Sleep Disorders in Dry Eye Patients

Humans spend approximately one third of their day sleeping. Healthy sleep is important for cognitive functioning and mood, as well as mental, cardiovascular, cerebrovascular and metabolic health. An adequate amount of sleep also plays a role in reducing the risk of accidents and injuries—including workplace accidents and motor vehicle crashes—caused by sleepiness and fatigue. Abnormal sleep patterns–such as short-term sleep deprivation, long-term sleep restriction, circadian misalignment and untreated sleep disorders can have a profound and detrimental impact on physical health, mental health and mood. Chronic insufficient sleep is associated with an increased risk of mortality and contributes to cardiovascular disease, diabetes, obesity and cancer.¹ The current increase in the number of patients with sleep disorders makes identifying modifiable risk factors and prevention strategies  clinically important.

As eye care professionals, we see first-hand the impact that dry eye has on our patients’ quality of life. We think about the detrimental effects of dry eye in our patients when they are awake, such as impacts on vision quality, ocular comfort or workplace performance, but emerging studies indicate that dry eye can also impact patients’ sleep quality due to incomplete eyelid closure, eye discomfort and mental stress. For example, Sjögren’s patients who have concomitant dry mouth often wake up in the night to consume water or instill ophthalmic lubricants, which disrupts their sleep. The purpose of the current study was to systematically review the association between dry eye and sleep disorders by performing a meta-analysis of existing observational studies that include scientific evidence for the prevention of sleep disorders.²

A comprehensive search was conducted in the PubMed, EMBASE, Cochrane, Web of Science and gray literature databases, and appropriate search strategies were developed using “dry eye” and “sleep disorder” as key words. The inclusion criteria for this study were: (1) subjects aged 18 years or older; (2) case subjects who were diagnosed with dry eye or Sjögren’s syndrome, with diagnostic criteria provided, and healthy individuals as control subjects; (3) provision of the number of bad sleep quality or sleep scores for both case and control subjects; (4) study type was observational research. Exclusion criteria were: (1) inappropriate article types such as reviews, meta-analyses, conference abstracts or case reports; (2) animal experiments; (3) unobtainable data or inappropriate data types; (4) duplicate publications or articles without full-text availability; (5) control subjects with other eye diseases.²

A total of 2,236 related articles were retrieved and, after applying the inclusion and exclusion criteria, 21 articles and 419,218 patients were included in the study. These patients were divided into 152,567 dry eye subjects and 266,651 healthy control subjects. Quality assessment of the chosen articles indicated that they were of moderate to high quality. The results showed the dry eye subjects had worse sleep quality than the healthy population, with poorer subjective sleep quality, longer sleep latency, and a higher risk of unhealthy sleep such as insufficient sleep duration or excessive sleepiness. Poor sleep quality in dry eye patients may be due to light exposure and discomfort caused by incomplete eyelid closure or pain from inflammation. Dry mouth discomfort experienced by Sjögren’s patients is also a contributing factor. Dry eye patients are also more likely to suffer from anxiety and depression, which can correspondingly affect sleep.²

References:

1. Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2021 Oct;17(10):2115–2119. doi: 10.5664/jcsm.9476
2. Gu Y, Cao K, Li A, et al. Association between sleep quality and dry eye disease: a literature review and meta-analysis. BMC Ophthalmol. 2024 Apr 5;24(1):152. doi:10.1186/s12886-024-03416-7.

Association between Sleep Quality and Dry Eye Disease: A Literature Review and Meta-Analysis

Yixuan Gu, Kai Cao, Ao Li, Jingyi Wang, Yihan Guo, Yiran Hao, Lei Tian, and Ying Jie
BMC Ophthalmol. 2024 Apr 5;24(1):152. doi: 10.1186/s12886-024-03416-7.

Objective: The purpose of this article is to systematically review the association between dry eye and sleep quality.

Methods: PubMed, EMBASE, Cochrane, Web of Science, and grey literature databases were searched for observational studies published before April 2023. Meta-analysis was performed using STAT15 software.

Results: A total of 21 studies with 419,218 participants were included. The results showed that the dry eye subjects had a worse sleep quality than the healthy population, with poorer subjective sleep quality, longer sleep latency, and a higher risk of unhealthy sleep duration such as insufficient sleep or excessive sleep. The Pittsburgh Sleep Quality Index (PSQI) scores of the dry eye subjects were significantly higher than those of the control subjects (WMD = 1.78, 95%CI: 1.06, 2.50, P < 0.001). The dry eye subjects scored higher than the control subjects in sleep quality, sleep latency, and sleep disturbance in PSQI; there was no difference between the dry eye individuals and control subjects in sleep duration, sleep efficiency, daytime dysfunction, and sleep medication scores. The risk of sleep disorders in the dry eye subjects was significantly higher than that in the non-dry eye subjects (RR = 2.20, 95%CI: 1.78, 2.72, P < 0.001); the risk of insufficient sleep in the dry eye subjects was higher than that in the control subjects (RR = 3.76, 95%CI: 3.15, 4.48, P < 0.001), and the prevalence of excessive sleepiness in dry eye subjects was higher than that in the control subjects (RR = 5.53, 95%CI: 3.83, 7.18, P < 0.001). The ESS scores of the dry eye subjects were significantly higher than those of the control subjects (WMD = 3.02, 95%CI: 2.43, 3.60, P < 0.01).

Conclusion: Our meta-analysis suggests that individuals with dry eye have a worse sleep quality than the healthy population, with poorer subjective sleep quality, longer sleep latency, and higher risk of unhealthy sleep duration such as insufficient sleep or excessive sleepiness.

New Technology for Improving Sleep

As an optometry student or even as a young optometrist, I never would have believed that I would, one day, talk about CPAPs (continuous positive airway pressure machines) as often as I do. As other contributors have noted, dry eye disease and CPAPs go hand-in-hand, like two peas in a rotten pod. For example, I frequently discuss mask design and fit with dry eye patients. Usually, I am met with sighs, eye rolls or some other manifestations of annoyance at not only the fact that they must wear a CPAP but also at the poor fit, the spurious air leakage and the discomfort. It’s fair to say that this area has a huge unmet need among those with obstructive sleep apnea (OSA).

Recently, the FDA cleared the Inspire V Upper Airway Stimulation system, the newest neurostimulator to treat OSA. The system includes a sensing lead, a stimulation lead and an implanted pulse generator. Together, these components monitor patients’ breathing patterns and  deliver an impulse to the tongue and chest when needed to allow opening of the airway and inspiration. 

In a clinical trial of 126 patients implanted with Inspire, the number of apnea-hypopnea events per hour decreased by 68%, and the number of oxygen desaturation events per hour decreased by 70%.¹ As expected, there was a meaningful reduction in daytime sleepiness and a meaningful improvement in quality of life.² While an implantable device may not be ideal for all OSA patients, those with moderate to severe disease who cannot tolerate traditional CPAP machines may find relief.

Although I have yet to encounter a patient who has Inspire V or any of its predecessors, I feel empowered knowing about this additional treatment option to share with my patients who suffer from both dry eye disease and OSA. A simple online search on Inspire’s website helped me find some local providers who are trained in the implantation procedures. To date, I wasn’t able to find any clinical trials that assessed dry eye disease pre- and post-Inspire implantation, but perhaps we should aim to change that in 2025! Here’s to a new year, full of robust clinical trials and abundant evidence-based eye care! 

References:

1. Strollo PJ, Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014 Jan;370(2):139-49. doi:10.1056/NEJMoa1308659
2. Tucker Woodson B, Strohl KP, Soose RJ, et al. Upper airway stimulation for obstructive sleep apnea: 5-year outcomes. Otolaryngol Head Neck Surg. 2018 Jul;159(1):194-202. doi:10.1177/0194599818762383