The decisions people make every day can influence many aspects of health, including ocular surface health. To bring recognition to possible effects of lifestyle choices on ocular surface health, the Tear Film & Ocular Surface Society (TFOS) initiated a novel global workshop called "A lifestyle epidemic: Ocular surface disease." It included 158 expert researchers from 38 countries.

The goal of the TFOS lifestyle workshop was to perform a literature review that raised awareness of the impact of lifestyle choices on the ocular surface, specifically addressing the impacts of contact lenses, cosmetics, digital environment, elective medications and procedures, environmental conditions, lifestyle challenges, and nutrition, on ocular surface health. For the benefit of the eye-care community, we summarize a few highlights from the topic reports below.

Contact lens

Approximately 140 million people globally wear contact lenses.¹ It is estimated that almost 100% of contact lens wearers will exhibit at least one contact lens hygiene risk behavior. These behaviors influence the success and safety of contact lens wear. One such common behavior is purchasing contact lenses through unregulated suppliers, including online retailers. About 23% of patients purchased contact lenses online, and the incidence has doubled since the COVID pandemic. Online contact lens purchases are more likely to be associated with serious ocular inflammatory events,² and these patients have increased risk of contact lens-related eye problems.

Additionally, we see increasing evidence that contact lens use with respiratory infections, such as COVID, is linked to increased corneal inflammatory events, so it is advisable for patients to pause contact lens wear when unwell. Lastly, the TFOS review of contact lens dropout found that discomfort followed by blurry vision are the two most common reasons for dropout. However, more studies are needed to elucidate lifestyle factors associated with contact lens dropout.

Cosmetics

Eye cosmetics often contain toxic chemicals that can lead to adverse ocular reactions if they contact the ocular surface. According to the Federal Drug Agency, an estimated 12,500 chemicals in cosmetic products perform a variety of functions other than cosmesis.³ For example, phthalates are solvents found in makeup removers that can disrupt corneal endothelial cell growth. The use of “natural” cosmetic products, which contain sustainable ingredients, is gaining popularity.

However, even natural compounds can impact ocular health. Isotretinoin, a vitamin A derivative commonly used to treat acne, has been demonstrated to impair meibomian glands through inflammatory mechanisms. Benzalkonium chloride (BAK) and formaldehyde, a human carcinogen, can be toxic to the ocular surface at levels well below the accepted regulatory limits.

Finally, the TFOS workshop also included a review of the effects of eyelash growth products. It suggested that these products may lead to meibomian gland dysfunction and dry eye symptoms.

Digital environment

Because digital technologies are becoming increasingly prevalent in our lives, the TFOS workshop sought to determine a unified definition of digital eye strain. They came up with, “the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing.” Symptomatology includes burning sensation, pain, headache, redness, photophobia, frequent blinking, and others.

Diagnostic algorithms are currently lacking but will be needed as digital eye strain is a growing issue that can impact productivity and quality of life through ocular discomfort, blurred vision, and musculoskeletal postural symptoms.

Methods to treat digital eye strain include appropriate distance refractive correction, automated reminders for regular breaks and blinking, proper screen ergonomics, and environments with increased humidity and decreased air conditioning. TFOS’s systematic review of studies identified that oral omega-3 fatty acid supplementation is a management option with a reasonable level of high-quality evidence suggesting its effectiveness. Current evidence found blue-light blocking glasses to be ineffective.

Elective medications and procedures

Elective medications and procedures can improve patients’ quality of life and can have distinct influences on ocular surface health. Commonly utilized systemic antihistamines are associated with dry eyes through decreased mucin production. Other systemic medications such as antimicrobials carry the risk of Stevens-Johnson syndrome — a vision-threatening, and potential life-threatening, reaction. Abruptly tapering some medications — such as corticosteroids — was also shown to increase risk of rebound ocular inflammation and conjunctival hyperemia.

Regarding elective procedures, cataract surgery impacts corneal sensitivity, as demonstrated by decreased corneal nerve fiber length seen 1 year post-operatively. Refractive error-correcting procedures including LASIK and photorefractive keratectomy are also associated with dry eyes through decreased blinking and tear secretion, as well as corneal nerve injury. The TFOS systematic review of SMILE, which does not create a corneal flap, is associated with more vision disturbances than LASIK in the first month but less dry eye symptoms in long-term follow up. However, more research is needed in this area.

Environmental conditions

Many variables contribute to the environment and can influence the ocular surface. Extremes of temperatures have been associated with increased dry eye symptoms. Corneal temperatures of 40° C/104° F are associated with changes in meibomian gland lipids, thus affecting the tear film. Other factors that increase dry eye symptoms include decreased humidity, increased wind speed, and higher altitudes.

Finally, The TFOS workshop performed a systematic review that evaluated the association between air, soil and water pollutants, and dry eye disease. It demonstrated that air pollutants such as NO2 and CO are probably associated with increased dry eye symptoms, while particulate matter of less than 10 micrometers had no impact.

Nutrition

Various aspects of nutrition — macro/micro-nutrients, diet, and gut microbiome — are important for maintaining overall health and can influence ocular surface health. It is well-known that supplementation with vitamins A, B12, C, and D improves dry eye symptoms.

There is evidence that omega 3 supplementation is beneficial for dry eye signs but not symptoms. Additionally, two studies found omega 3 supplementation increased corneal nerve branch density and fiber length, which could represent a form of corneal neuroprotection, though more studies are necessary.

There is preliminary evidence that other aspects of nutrition such a healthy gut microbiome is associated with decreased dry eye symptoms, and it has been hypothesized that modulating the makeup of the microbiome could be a future target of dry eye treatment.

Similarly, the TFOS review of different forms of food restriction (bulimia, anorexia nervosa) did not have conclusive studies.

Lifestyle challenges

This workshop explores the impact of mental, physical, social health, and psychosocial factors on ocular surface disease. Some mental health disorders, such as depression, anxiety, and sleep disorders, are associated with increased risk of dry eye disease symptoms. However, correlation with dry eye disease signs (Schirmer’s test, tear break-up time, meibomian gland dysfunction) is unproven.

Regarding physical health, obesity is linked to meibomian gland atrophy and tortuosity; however, reports on the association of obesity with dry eye disease are mixed. Additionally, the TFOS workshop’s review of chronic pain disease revealed that other physical health conditions, including migraine, chronic pain syndrome, and fibromyalgia, have increased comorbidity with symptoms of dry eye disease.

Lastly, the TFOS review established the COVID-19 pandemic increased the risk of developing or exacerbating ocular surface disease through increased screen time and decreased access to eye services.

Want more information?

The above takeaways are just a few of the myriad pearls contained in the roughly 400-page report that was published in April 2023's The Ocular Surface. An Executive Summary of the full report was also recently published (https://www.sciencedirect.com/science/article/pii/S1542012417302148 ). For more information on the TFOS Workshops, please visit www.tearfilm.org . OP

REFERENCES:

1. Dumbleton K, Caffery B, Dogru M, et al. The TFOS International Workshop on Contact Lens Discomfort: report of the subcommittee on epidemiology. Invest Ophthalmol Vis Sci. 2013;54:TFOS20-TFOS36.
2. Sorbara L, Zimmerman AB, Mitchell GL, et al. Multicenter Testing of a Risk Assessment Survey for Soft Contact Lens Wearers With Adverse Events: A Contact Lens Assessment in Youth Study. Eye Contact Lens. 2018;44:21-28.
3. Cosmetic Ingredient Review (Cir). Cosmetic Ingredient Review procedures & support to the expert panel for cosmetic ingredient safety (2019). https://www.cir-safety.org/sites/default/files/CIR%20Procedures%20-%20September%202019.pdf . Accessed October 12, 2023.

Quillan M. Austria, MD, received his medical degree from Weill Cornell Medicine. He is currently an ophthalmology resident at New York Presbyterian Hospital-Weill Cornell Medical College.

Christopher E. Starr, MD, is an associate professor of ophthalmology at Weill Cornell Medicine, New York-Presbyterian Hospital, New York City. He is the director of Ophthalmic Education, director of the Cornea, Cataract, & Refractive Surgery Fellowship, and director of the Refractive Surgery Service. He is a Global Ambassador for the Tear Film & Ocular Surface Society and serves as chair of the Public Awareness Subcommittee for the Lifestyle Epidemic: OSD workshop.