Presented by The Wilmer Eye Institute, Johns Hopkins Medicine in Baltimore, Maryland, USA Visit https://health.usnews.com/health-care/articles/2018-11-20/another-dry-eye-harm-slowed-reading for more information. Research & Presentation Credit: Sezen Karakus, M.D. Priya Mathews, M.D., M.Ph. Devika Agrawal Claudia Henrick, M.D. Pradeep Y. Ramulu, M.D., PhD Esen K. Akpek, M.D.

1. Impact of Dry Eye on Prolonged
Reading
The Wilmer Eye Institute
Baltimore, Maryland, USA
1
Sezen Karakus, MD;
Priya Mathews, MD, MPH,
Devika Agrawal;
Claudia Henrich, MD;
Pradeep Y. Ramulu, MD, PhD;
Esen K. Akpek, MD.

2. Financial Disclosure
• No financial disclosure
• Supported in part by an investigator-initiated research
grant from Allergan, Inc.
• Grant provided by Jerome L. Greene Sjögren’s Center,
Johns Hopkins University, Baltimore, MD.
• The TMS-4 videokeratoscopy was provided by Tomey
(Waltham, MA) for the duration of the study.
*The funding organizations had no role in the design or conduct of this research.
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3. Background
• Dry eye symptoms affect up to 30% of
population over the age of 50
• Reading difficulty one of the most common
symptoms of dry eye
• Reading is necessary for both leisure and
work-productivity
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4. Reading Speed in Dry Eye
• All reading tests use relatively brief passages of
text – usually no more than 200 words
• However, frequent complaint of patients with dry
eye is that they cannot sustain reading for longer
than 10-15 minutes.
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5. Hypothesis
“Short-duration reading tests may not
accurately reflect the real effect of dry eye on
reading”
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6. Patients
• 50 years and older
• Binocular vision ≥ 20/25
• Dry eye patients recruited from the Ocular Surface
Diseases and Dry Eye Clinic, the Wilmer Eye Institute,
Johns Hopkins University, Baltimore, MD
• Controls: similarly aged friends, family members,
volunteers
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7. Methods
• Vision measures (BCVA, CS, Reading acuity, CPS)
• OSDI symptom questionnaire
• Non-invasive TBUT using TSAS
• Videokeratoscopy for surface irregularity indices (SAI and
SRI)
• Schirmer’s test without anesthesia
• Corneal fluorescein staining and conjunctival lissamine
green staining graded according to SICCA
• Visual Fatigue using a visual analogue scale
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8. Evaluation of Reading Speed
1. IReST excerpt: short-duration out-loud
2. Sustained silent reading test*: 7200-word
reading passage for 30-minute reading
• Reading speed calculated in words per minute (wpm)
• Comprehensive questionnaire for silent reading
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*Ramulu PY, et al. Invest Ophthalmol Vis Sci. 2013;54:673–
80.

9. Definition of Study Groups
1. Clinically significant dry eye
➢ OSS≥3 in either eye on the day of the study exam,
irrespective of OSDI score
2. Dry eye symptoms only
➢ OSS<3 but OSDI score >12
3. Controls
➢ OSS<3 and OSDI score <12
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10. Results
• 200 enrolled
– 3 withdrew
– 11 excluded due to poor comprehension and/or
anomalous reading speed
– 186 included for analysis
• 116 clinically significant dry eye
• 39 dry eye symptoms only
• 31 controls
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11. Characteristics
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Clinically
SignificantDry
Eye (n=116)
Dry Eye
Symptoms
Only (n=39)
Controls
(n=31) P value
DEMOGRAPHICS
Age, years 64.6±8.9 62.1±6.3 60.8±5.7 0.03
Female, n (%) 91 (78%) 25 (64%) 19 (61%) 0.07
VISION MEASURES
VisualAcuity, logMAR -0.03±0.1 -0.08±0.1 -0.03±0.1 0.03
ContrastSensitivity, log 1.59±0.12 1.66±0.09 1.64±0.07 0.001
MNReadReading Acuity, logMAR 0.04±0.14 -0.01±0.10 0.02±0.11 0.08
Critical Print Size, logMAR 0.18±0.13 0.13±0.13 0.15±0.15 0.12

12. Subjective Dry Eye Measures
Clinically
Significant Dry
Eye (n=116)
Dry Eye
Symptoms
Only (n=39)
Controls
(n=31) P value
Total OSDI Score, 0-100 32.8±23.5 31.4±17.6 4.4±3.9 <0.001
Discomfort-Related Subscore, 0-50 17.9±13.2 18.7±9.2 3.4±3.2 <0.001
Vision-Related Subscore, 0-50 14.9±12.1 12.9±10.9 1.1±1.9 <0.001
Reading difficulty present, n (%) 72 (62%) 22 (58%) 1 (3%) <0.001
Visual Fatigue Score, 0-10 2.4±2.5 2.1±2.3 1.2±1.5 0.07
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13. Objective Dry Eye Measures
Clinically
SignificantDry
Eye (n=116)
Dry Eye
Symptoms
Only (n=39)
Controls
(n=31) P value
TearBreak-UpTime, s 2.4±2.9 3.4±3.5 3.3±3.8 0.15
Surface Irregularity Indices
Surface Asymmetry Index (SAI) 0.59±0.29 0.56±0.29 0.69±0.45 0.29
Surface Regularity Index (SRI) 0.57±0.29 0.56±0.30 0.57±0.32 0.98
Schirmer’s Test, mm 10.5±6.8 14.1±9.7 15.3±8.6 0.002
OcularStaining Score (OSS), 0-12 6.3±2.7 1.1±0.8 0.9±0.9 <0.001
Corneal Staining, 0-6 3.1±1.6 0.7±0.7 0.6±0.7 <0.001
Conjunctival Staining, 0-6 3.3±2.1 0.5±0.7 0.4±0.6 <0.001
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14. Reading Speed
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146 152 153
240
255
272
0
50
100
150
200
250
300
350
Clinically Significant Dry Eye
(n=116)
Dry Eye Symptoms Only (n=39) Controls (n=31)
.
Out-Loud Sustained Silent
ReadingSpeed(wpm)
*
* Significant difference

15. MultivariableAnalysis of Reading Speeds
according to Dry Eye Status
Out-Loud Reading Speed SustainedSilent Reading Speed
wpm change (95% CI) n P value wpm change (95% CI) n P value
Clinically Significant Dry
Eye vs. Controls
-5.2 (-17.4 to 6.9) 147 0.39 -27.9 (-53.6 to -2.2) 147 0.03
Dry Eye Symptoms Only
vs. Controls
0.03 (-11.9 to 11.9) 70 0.99 -17.4 (-51.8 to 16.9) 70 0.31
Clinically Significant Dry
Eye vs. Dry Eye
Symptoms Only
-4.6 (-15.5 to 6.2) 155 0.40 -12.8 (-35.4 to 9.9) 155 0.27
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*adjusted for age and sex

16. Associationsof Subjectiveand ObjectiveMeasures of Dry
Eye with Out-Loudvs. SustainedSilent ReadingSpeed
Out-Loud Reading Speed SustainedSilent Reading Speed
wpm change (95% CI) P value wpm change (95% CI) P value
Total OSDI Score (0-100) -0.04 (-0.2 to 0.1) 0.65 -0.5 (-0.9 to 0.06) 0.02
Discomfort-Related Subscore (0-50) 0.03 (-0.3 to 0.4) 0.86 -0.6 (-1.4 to 0.1) 0.10
Vision-Related Subscore (0-50) -0.2 (-0.5 to 0.2) 0.28 -1.0 (-1.7 to -0.2) 0.02
Visual Fatigue Score (0-10) -1.9 (-7.8 to 0.1) 0.06 -2.8 (-7.6 to 1.9) 0.24
Tear Break-Up Time, s 0.004 (-1.3 to 1.3) 0.99 -2.3 (-5.2 to 0.6) 0.11
Surface IrregularityIndices
Surface Asymmetry Index (SAI) 5.4 (-8.8 to 19.5) 0.45 18.2 (-16.1 to 52.5) 0.30
Surface Regularity Index (SRI) 4.0 (-11.5 to 19.6) 0.60 8.3 (-29.5 to 46.2) 0.66
Schirmer’s Test, mm 0.2 (-0.3 to 0.7) 0.51 0.2 (-1.0 to 1.3) 0.79
Corneal Staining (0-6) -2.6 (-6.1 to 0.9) 0.15 -10.0 (-18.0 to -2.1) 0.01
Conjunctival Staining (0-6) 0.1 (-1.7 to 2.0) 0.90 -1.1 (-5.3 to 3.2) 0.63
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*adjusted for age and sex

17. Can Symptoms Be Explained by
Corneal Staining Only?
• Corneal staining included in linear regression
model (while controlling for age and sex)
➢Vision-related OSDI score remained significantly
associated with sustained silent reading (-0.8 wpm per 1
point increase in score, 95% CI: -1.6 to -0.04, P = 0.04)
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18. Conclusion
• Prolonged reading speed more profoundly
affected in dry eye (10% vs. 3%)
– Not statisticallysignificant decrease in short-durationout-loud
• Corneal punctate erosions predicting this
reduction
– Either discomfort or blur or both
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19. Thank you for your
attention!
December 3, 2018 19