Introduction
The COVID-19 pandemic has had a large impact on the eye health of the people who uses digital devices for the longer period of time. Digital screen timing, excessive near work and limited outdoor activities are the key factors behind the eye strain among these groups.1
Osmoprotective tear drops are most commonly used drugs for the management of any dry eye related symptoms. These drugs are easy to use, accessible to wide range of varieties and also have a low risk potential. So, it has been found that symptomatic VDT users have a tendency to buy Osmoprotective drugs from medicine shops without any valid ophthalmic prescription by a registered medical practitioner.2, 3
OTC-purchased eye drops may provide advantages like easy access to medicines and self-treating with minimal complications with the help of a pharmacist. However, it is not always safe and answers for all types of ocular conditions especially when the condition is not properly diagnosed by an expert. As a result, there is often a chance of not adhering to the compliance rate in terms of dosage, instructions to use, drug discontinuation schedule, etc.4
OTC eye drop users are therefore faced with a perplexity of variable products and very little or no clear understanding or knowledge of which one is most effective. On the other hand, a prescription by a registered ophthalmology practitioner after the complete evaluation of the clinical condition, diagnostic tests, and proper diagnosis may help to choose the appropriate eye drops with specific dosage and also take care of any specific drug allergy or co-morbid conditions.5
Thus we intend to take up this study to find the correlations between the OTC dispensing pattern and ophthalmologist prescription pattern of Osmoprotective drugs among prolonged VDT users.
Materials & Methods
This study was a cross sectional, questionnaire based conducted on 100 patients those who were visited to the outpatient department of hospital. All the participants were given a detailed explanation of the study and informed consent were signed. The necessary permission from research committee were obtained from the concerned to conduct the study. Inclusion criteria includes (i) Above 18years of age or older irrespective of any gender (ii) Subjects are prolonged VDT users at least 6 hours/day or more (iii) Not visited to any ophthalmologist in recent past within 3 months of period (iv) Subjects those who are using only over the counter Osmoprotective drugs within last 3 months. We have excluded the subjects those who are using any other ocular drugs other than dry eye condition. Any medical professionals such as Doctor, Nurse and Pharmacist etc. were also excluded & those who had undergone ophthalmic surgery within 6 months’ period.
Data collections involved in filling up a questionnaire as a self-completion task with instructions provided for each questions. Questionnaire used for this study were used in earlier published literature where we have done only few minor iterative modifications as per the need of our work.6
After completion of the questionnaire all the subjects were assessed for detailed clinical history and ocular examinations for both the eyes. Schirmer’s-II test were performed with topical anesthesia as a baseline diagnostic tests to diagnose the dry eye conditions. A value of >15 mm of wetting: Normal, 10 mm – 15 mm: Mild dry eye,5 mm – 10 mm: Moderate dry eye, 0 mm – 5 mm: Severe dry eye as per the literature.7 Subjects were prescribed with Osmoprotective drugs as per their clinical diagnosis by the ophthalmologist.
Results
A total of 100 subjects were included. The average age of participants was approximately 36+ 9 years. On average, participants spent around 8.5+2.3 hours/day using Visual Display terminal (VDT) devices. Table 1 presents insights into the other demographic and background characteristics.
In finding the number of days unable to follow the prescribed frequency, the analysis of variance (ANOVA) results revealed a statistically significant difference across different severity levels of eye symptoms (F = 2.905, p<0.026). Specifically, individuals with moderate symptoms had the lowest average number of days (16.25 ± 5.98), followed by those with severe symptoms (17.11 ± 4.93), mild symptoms (19.43 ± 3.78), and no symptoms (20.67 ± 2.73).
The compliance rate is calculated using the variable "Number of days unable to follow the prescribed frequency of dry eye treatment eye drops in a month (Days)" by assessing the number of days able to follow the prescribed frequency of dry eye treatment. Therefore, the average compliance rate is 41%.
Table 1
Patient background and other information
Table 2
Association between severity of eye symptoms before and after eye drop treatment
Table 3
Association between severity of eye symptoms in the last 1 month and drug instillation behaviour
Table 4
Association between severity of eye symptoms in the last 1 month and reasons for non-compliance with instructed frequency by the pharmacist
Table 5
Association between over the counter (OTC) drug prescription pattern and Schirmer’s test-II results for right eye & left eye
Table 6
Association between prescribed medicine by ophthalmologist and Schirmer’s test-II results for right eye & left eye
Table 7
Association between prescribed medicine by ophthalmologist and diagnosis of right and left eye
Table 8
Association between the OTC prescription and ophthalmologist prescription
Discussion
Our study provides a detailed insight into the use of over-the –counter medication in patients with dry eyes. A significant majority (86%) had not visited an ophthalmologist for an eye drop prescription in the past 2.264+0.8 years, suggesting that over-the –counter eye drops were the most commonly used medication by all participants. As also described in previous studies, patients often consult the pharmacist for minor symptoms.8
The results of the Schirmer’s-II Test (Table 1) showed that on average, participants had a moisture levels of DED. These scores indicate that most participants experienced mild dry eye symptoms in both eyes. This is an evident that self-medication is significantly increasing when the problem is minor.9
Figure 1, Figure 2 presents carboxymethyl cellulose emerged as the most commonly used OTC drug followed by Sodium hyaluronate ophthalmic solution (0.1% or 0.3%) and Polyethylene glycol and polypropylene glycol. This finding showed similar kind of results to previous studies.10
In Table 2 the chi-square test results showed a significant association was observed between the severity levels before and after treatment (p < 0.000), indicating that the treatment had a noticeable impact on symptom severity.11
In Table 3 the findings showed that adhering to a fixed frequency of instillation, irrespective of subjective symptoms, could moderately alleviate symptoms for a significant portion of individuals (71.4%). Conversely, those who used eye drops solely in response to subjective symptoms demonstrated a more diverse spectrum of symptom severity, with a higher proportion (67.4%) experiencing moderate to severe symptoms. The Chi-square test indicated a significant association between the pattern of eye drop usage and symptom severity p<0.033).
In the case of instructions received on the frequency of eye drop usage, the Chi-square test reveals a significant association between the instructions received and symptom severity (p <0.038). From the results, it can be evidenced that prescribing 2 drops may be the most appropriate initial dosage for managing dry eye symptoms, as it provides relief for a significant portion of patients while minimizing the risk of exacerbating symptoms. However, individualized treatment plans tailored to each patient’s specific needs and responses should always be considered to optimize therapeutic outcomes.
In finding the association with compliance rate (Figure 3 & Table 4) participants who strongly agreed to use eye drops after feeling symptoms, reported a substantial proportion experiencing severe symptoms, with 37.6% experiencing severe symptoms and 17.6% reporting very severe symptoms. This association is significant (p<0.016). Participants strongly agreed that their symptoms were relieved with the eye drop treatment (p<0.003).
For participants who agreed that they experienced brightness, discharge, or bitterness after using eye drops the association is significant for them too (p<0.03). Participants who agreed that using the eye drops was uncomfortable predominantly reported moderate to severe symptoms. (p<0.032). A significant no of subjects have also disagreed on the point that eye drops ruin makeup (p<0.008).12
In interpretation of ANOVA results, showed that individuals without any symptoms appeared not to adhere more closely to the prescribed regimen compared to those with symptomatic conditions, suggesting that the presence of symptoms may influence participants’ adherence to the recommended eye drop frequency.
Although no significant associations were found between the type of OTC drug prescription and the severity of dry eye symptoms in the right & left eye overall (Table 5), a notable exception was observed for users receiving specific Instructions (Ex: Hot fomentation), indicating a significant relationship between these instructions and Schirmer’s-II results. These findings indicate an association between OTC drug usage and symptom severity in dry eye management, suggesting the importance of personalized treatment approaches meant for individual needs and responses.
In Table 6 the association between prescribed medicine by the Ophthalmologist and Schirmer’s Test-II results for the both right and left eye showed that patients who are using antibiotics and other medicines are more prevalent in the mild group compared to the other group.
Table 7 resents associations between prescribed medications by ophthalmologists and the diagnosis of various dry eye conditions. Most respondents who were prescribed 0.1% or 0.3% Sodium hyaluronate ophthalmic solution and CarboxymethylCellulose are suffering from mild dry eye. Most respondents who were prescribed antibiotics and other medicines are suffering from moderate dry eye.
In illustrating the association between prescribed drugs and OTC drugs (Table 8) it is found that, for Carboxymethyl Cellulose, out of the 57 patients prescribed this medication by an ophthalmologist, a significant majority of 89.5% were also directed to use it as an over-the-counter (OTC) purchased, while only 10.5% were not (p < 0.003). Polyethylene glycol and polypropylene glycol had an association, where 62.5% of the 16 patients receiving it as an Ophthalmologist prescription were also directed to obtain it as an OTC prescription, and 37.5% were not. (p < 0.000).13 The distribution of prescribed medications by ophthalmologists reveals distinct patterns across different diagnoses of dry eye severity. Our study only showed associations for 2 drugs including Carboxymethyl Cellulose & Polyethylene glycol and polypropylene glycol between OTC purchase and Ophthalmologist’s prescription. Other dry eye medications may be needed considering the severity of the dry eye conditions. Therefore, OTC drugs may not be the answer for all subjects. Clinical diagnosis has a major impact on deciding the choice of drug even if the condition is minimal. Otherwise, the symptoms may last longer due to improper drug choices. With the advancement of digitalization, in the coming days dry eye could impact the quality of life of a considerable number of population.
This study has a few limitations too. The population of this study is relatively less. To diagnose dry eye only Schirmer’s II test has been performed, other tests could not be investigated. Therefore, further studies may be needed.
Conclusion
Therefore, based on our findings and previous study reports we can say, that our work gives a detailed insight into drug usage patterns purchased from OTC. This study also found a correlation between OTC drugs and ophthalmologist-prescribed drugs. To achieve an improved compliance rate in drug usage it’s always advisable to know the reasons behind non-adherence to eye drop usage.
