key: cord-0840317-kainoavl authors: McKenna, C. G.; Ibrahim, P.; Mather, R. title: Virtual Assessment of Patients with Dry Eye Disease During the COVID-19 Pandemic: One clinicians experience date: 2022-03-09 journal: nan DOI: 10.1101/2022.03.07.22272050 sha: 12593fface8de10c94d9e2fadefaa21f807f1765 doc_id: 840317 cord_uid: kainoavl Objectives To report on 1) the impact of DED on social, mental, and financial well-being, and 2) the use of virtual consultations to assess DED during the COVID-19 pandemic. Design & Methods An exploratory retrospective review of 35 charts. Telephone consultations for patients with DED conducted during the first lock-down period in Ontario in 2020 were reviewed. Results The most commonly reported DED symptoms were ocular dryness, visual disturbances, and burning sensation. The most common dry eye management practices were artificial tears, warm compresses, and omega-3 supplements. 20.0% of charts documented worsening of DED symptoms since the onset of the pandemic and 17.1% reported the lockdown had negatively affected their ability to perform DED management practices. 42.8% of patients reported an inability to enjoy their daily activities due to DED symptoms. 52.0% reported feeling either depressed, anxious, or both with 26.9% of patients accepting a referral to a social worker for counselling support. More than a quarter of the charts recorded financial challenges associated with the cost of therapy, and more than a fifth of patients reported that financial challenges were a direct barrier to accessing therapy. Conclusions Patients living with DED reported that their symptoms negatively affected their daily activities including mental health and financial challenges, that in turn impacted treatment practices. These challenges may have been exacerbated during the COVID-19 pandemic. Telephone consultations may be an effective modality to assess DED symptom severity, the impact of symptoms on daily functioning, and the need for counselling and support. 126 Participant Demographics: All charts (n= 35) recorded age, sex, general health history, including previously diagnosed Sjörgren's syndrome, 128 co-morbidities and systemic medications. All charts also documented ocular health history, dry eye history, ocular 129 topical medications and other DED treatments, and frequency of optometric care. A total 35 patients completed the 130 first part of the consultation interview with the clinical assistant. While not all patients answered every question, all 131 completed questions were analyzed in the chart review as a proportion of those that did answer the question. On 132 average, patients reported experiencing DED symptoms for 6.14 years prior to ophthalmology consultation and 133 visiting their optometrist 1.61 times per year regarding DED (Table 1) . A fifth of charts documented patients with a 134 pre-existing diagnosis of Sjögren's syndrome. 78.13% of charts documented a DEQ-5 score equal to or greater than 135 12, suggesting Sjögren's related DED and warranting further work-up. 21.21% of charts documented severe DED 136 symptoms and 48.48% had moderate DED symptoms according to CDEA scores equal to or greater than 31. 6.14 years . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 The most common management practices among patients were artificial tear use (82.86%), warm compresses 145 (71.43%), and omega-3 supplements (42.86%) ( . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Other 2 18.18% Spearman's Rho analysis revealed that there was no significant correlation between DEDM scores and DEQ-5 151 scores (Table 3) . However, there were significant correlations between number of artificial tears used per day and 152 DEQ-5 score (P=0.009), between number of artificial tears per day and DEDM scores (P<0.001), and between number of artificial tears used per day and number of visits to eyecare provider per year (P=0.008). watching TV (26.08%), and driving (17.39%) (Fig 2) . As part of routine DED consultations, patients were screened 161 for mental health challenges and asked to comment on the severity of their challenges as well whether they wished . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10. 1101 /2022 to be referred to social work team at the hospital for additional support. 48.00% of charts reviewed indicated no accepted a referral to speak with a social worker when offered. More than a quarter of the charts documented 165 patients reporting financial challenges associated with their DED. Similarly, more than a fifth of patients revealed 166 that financial challenges were a barrier to accessing DED therapy. One fifth of charts documented worse DED symptoms during the lockdown period compared to prior to the 171 lockdown period (Table 5 ). 17.14% of patients reported the lockdown negatively affected their ability to perform 172 their DED self-care routine, 2.00% reported their self-care routine was better during the lockdown, and the 173 remaining indicated no change. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. Sjogren's disease. In terms of treatment, telephone consultations allowed for initiation of optimal DED management, and allowed for triaging patients for subsequent in-person assessment. DED symptoms and self-care: In this preliminary chart review, patients were referred to a cornea specialist after an average of 6 years of DED 186 symptoms, and almost three quarters of patients had moderate or severe DED symptoms according to CDEA scores. The majority of patients reported using artificial tears and warm compresses, and less than half reported using despite the severity of symptoms reported. Among those who took omega-3 supplements, approximately one third 190 were taking less than the 2000 mg recommended daily dose. With the information obtained, patients were 191 counselled regarding optimal DED self-management and educated regarding optimal follow-up and future treatment 192 modalities. The DEDM score is a novel parameter created to capture overall DED management practices employed by patients. This measure allows researchers to understand how many of the five main practices were employed, to get a sense 196 of self-management in totality. The composite score is a novel way to assess the relationships between patient 197 treatment behaviours/practices and disease severity. A significant correlation was identified between the frequency of artificial tear use and DEQ-5 scores. This was 200 expected as worse symptoms intuitively warrant more tear use per day. In addition, the frequency of artificial tear . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101/2022.03.07.22272050 doi: medRxiv preprint use was correlated with overall DED management composite scores. Perhaps respondents who use tears more often 202 are also more diligent about other elements of their DED self-care, or have the financial means to engage in more 203 elements of self-care. The frequency of artificial tear use correlated with the number of eyecare visits per year, 204 suggesting that more severe DED symptoms may lead to greater healthcare seeking behaviour. Financial means 205 and/or insurance coverage allow patients to afford the cost of both artificial tears and additional eye care 206 appointments. Moreover, seeing an optometrist more frequently may increase the likelihood of adherence to therapy. 207 208 DED and financial barriers to therapy: Financial barriers associated with therapy may lead to poor adherence to DED self-care. Nearly a quarter of patients 210 reported that the cost of dry eye therapy was a deterrent to therapy adherence. This is consistent with other studies 211 that reported the cost of DED therapy represented an average annual out of pocket expense of $1,089 CAD per 212 year (14) and $678-$1,267 USD per year(15). Moreover, this study found patients to be underutilizing artificial tears 213 and omega-3 supplements. Financial barriers promote rationing of artificial tears and other therapeutics, as reported 214 by Michaelov et al. (14) . In addition, financial struggles are likely underreported by patients to eye care providers as 215 previous studies have shown that non-adherence to therapy due to financial reasons is often not disclosed by patients 216 to their health care providers(14). Furthermore, the COVID-19 pandemic has resulted in financial stressors for a 217 large proportion of the population, as reported in a study that found 40% of US adults experienced COVID-19-218 related financial stressors from March to August 2020(16). In this study population, patients visited their optometrist an average of 1.61 times per year. Interestingly, there was 221 no correlation between frequency of visits and symptom severity. For some patients, insurance coverage may limit 222 visits to once per year. The lack of private insurance coverage may also be a financial barrier to care. Literature 223 demonstrates that lack of government-insured optometric services was found to negatively impact patients' access to 224 health care services, and ultimately vision health outcomes(17). However, these would be an important relationships 225 to evaluate in a larger study sample. DED and mental health: . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10. 1101 /2022 In this study, over half of patients reported either anxiety, depression, or both, as a result of DED symptoms. This issues including anxiety and depression (6, 18) . Over a quarter of patients accepted a referral to a social worker for support regarding living with DED. These One fifth of patients reported the pandemic made their DED symptoms worse, and 17% reported it negatively 250 affected their ability to perform their DED self-care. Only 2% reported their symptoms improved. Nearly half of 251 patients reported spending more time using screens, which may be contributing to the worsening symptoms. Many non-essential medical visits and procedures were postponed due to provincial public health directives. In 254 many cases, this resulted in a negative impact on health outcomes. Through virtual consultations, the patients in this 255 study were assessed and counselled with respect to optimizing their DED self-care management. Despite the lack of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101/2022.03.07.22272050 doi: medRxiv preprint physical exam findings such as VA, IOP, and SLE, virtual appointments may serve as a valuable way to initiate management until in-person visits are possible. Moreover, telephone appointments constitute a form of virtual care 258 that doesn't involve apps or video chat, making the modality user-friendly for both clinicians and patients. This is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 were obtained from optometrist and ophthalmologist referral letters, the lack of contemporaneous VA, IOP, and SLEs may represent a limitation to care. 288 Telephone consultations for patients with DED may be an effective way to assess dry eye disease symptom severity, 289 the impact of symptoms on daily functioning, and the need for counselling and support. In this chart review, 290 patients living with DED reported symptoms that negatively affected their daily activities including mental health 291 and financial challenges, which in turn impact their ability to perform dry eye management activities. These . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 9, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 9, 2022. Going out in public like grocery shopping or to the mall . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 9, 2022. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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Mental Health of Canadians During the COVID-19 Pandemic Canadian Mental Health Association. New data shows majority of Ontarians believe mental health crisis 22 Teleophthalmology: an essential tool in the era of the novel coronavirus Competing Interests: All authors certify that they have no affiliations with or involvement in any organization or