TFOS lifestyle: Impact of societal challenges on the ocular surface

**Background:** This report is part of the Tear Film & Ocular Surface Society (TFOS) Workshop, entitled ‘A Lifestyle Epidemic: Ocular Surface Disease,’ which was undertaken to establish the direct and indirect impacts that everyday lifestyle choices and challenges have on ocular surface health. It examines societal challenges in ocular surface diseases using an adaptation of a framework used to map the relationship between the individual, their environment and their health. The report focuses on how societal factors contribute to norms that influence presentation, outcome and management of ocular surface diseases, rather than the direct biological effects of lifestyle factors, which are covered in other TFOS reports. A key issue given the timing of this report was the impact of COVID-19 on the ocular surface, and a systematic review was conducted to summarize this impact.

**Methods:** The report is a narrative-style review that, wherever possible, refers to outcomes from high-quality systematic review (Level I) evidence. The Evidence Quality Subcommittee provided a comprehensive database of appraised Level 1 evidence. Additionally, a systematic review was conducted to summarize the impact of the COVID-19 pandemic on the frequency and severity of ocular surface disease in both the general population and amongst those who had COVID-19. This systematic review was prospectively registered through PROSPERO (CRD42022299681). PubMed was searched from January 1, 2019 to December 14, 2021 and Embase from January 1, 2019 to January 4, 2022. Published primary comparative studies with at least 50 participants overall were included. The database searches yielded 9338 unique records, and after screening 129 full-text reports, 40 studies were included.

**Key Results:** Age is a significant risk factor for many ocular surface diseases, including dry eye disease, meibomian gland dysfunction, blepharitis, conjunctivochalasis, pinguecula, pterygium, infectious keratitis and ocular surface tumors. Increasing age is a fairly robust risk factor for dry eye disease in population-based cross-sectional studies, with four systematic reviews and meta-analyses supporting an increase in dry eye prevalence with age. Females have approximately twice the risk of dry eye disease compared to males in population studies. South-east Asians appear to have 1.5-2x the risk of dry eye disease and meibomian gland dysfunction compared with Caucasians. Heritability in dry eye disease is approximately 30% for symptoms and 40% for a prior diagnosis. Co-morbidities associated with more severe dry eye disease include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, and anxiety. Smoking has not been confirmed as a risk factor for dry eye disease in population-based studies, with the largest Lifelines study showing a reduced risk in current smokers but a higher risk in previous smokers. Alcohol consumption was a significant risk factor for dry eye disease in a meta-analysis of 10 studies, irrespective of age and sex. The systematic review of COVID-19 impacts found that increased screen time during the pandemic resulted in new symptoms of dry eye disease and worsening of ocular surface disease-related signs and symptoms across all age groups. Prolonged face mask wearing negatively affected people with dry eye, as evidenced by increased ocular surface inflammation, decreased Schirmer scores, and decreased tear break-up time. Of the 40 included studies, 9 (23%) were rated at high risk of bias, 25 (63%) at moderate risk, and 6 (15%) at low risk.

**Clinical Implications:** The report demonstrates that societal challenges are associated with both acute and chronic ocular surface diseases. With an increase in longevity and the rapidly growing number of older populations, it is expected that age-related ocular surface diseases will result in significant social and economic cost. The findings suggest that patients who have dry eye symptoms warrant early evaluation and timely intervention regardless of their age. The systematic review established that the COVID-19 pandemic and the various mitigating strategies or their consequences, including increased screen time and online learning, were associated with an increased risk of developing new or worsening pre-existing ocular surface diseases. Given the longer-term changes in remote or flexible work and study practices, it seems reasonable to assume that increased frequency and severity of these conditions will persist beyond the immediate pandemic. The report emphasizes that addressing societal factors at a health policy level is essential, and that interventions should target the interplay and dependencies between different factors including access to care, education, poverty, and cultural practices.