Awareness About Dry Eye Symptoms and Risk Factors Among Eastern Province Population in Saudi Arabia

Background Dry eye syndrome (DES), also known as keratoconjunctivitis sicca (KCS), is a common cause of patient's visits to the ophthalmologist. It is characterized by a defect in the tear film homeostasis, symptoms of ocular discomfort, and visual disturbance. Also, it increases the risk of ocular surface damage if complicated by tear film hyperosmolarity and ocular surface inflammation. The present study aims to measure awareness about dry eye disease and the risk factors among the Eastern region population in Saudi Arabia via an online questionnaire. Methods This is a cross-sectional community-based study conducted in Saudi Arabia that assessed knowledge and awareness of dry eye among the eastern province population using a self-administered online questionnaire. The minimum sample size was 385 adults. Statistical analysis was performed using SPSS software, version 21.0 (IBM Corp., Armonk, NY), and participants' overall awareness level was evaluated based on correct answers. Results In this study, a total of 522 participants fulfilling the inclusion criteria completed the study questionnaire. Participants ranged from 18 to 65 years, with a mean age of 27.2 ± 14.6 years old. Females represented a higher percentage of the sample, 341 (65.3%). Public awareness regarding dry eye diseases in the Eastern region, Saudi Arabia of 149 participants (28.5%) is overall a good awareness level while 373 (71.5%) of them had poor awareness. Conclusion Participants showed unsatisfactory results in awareness of risk factors of dry eye symptoms, where the most reported causes were prolonged concentration while using electronic devices, climatic factors, and lacrimal gland disorders.


Introduction
Dry eye syndrome (DES), also known as keratoconjunctivitis sicca (KCS), is considered a common cause of patient visits to the ophthalmologist [1].The International Dry Eye WorkShop (2007) defined DES as follows: Dry eye is a multifactorial disease characterized by a defect in the tear film homeostasis and symptoms of ocular discomfort and visual disturbance, with increased risk of ocular surface damage if complicated by tear film hyperosmolarity and ocular surface inflammation [2].The tear film consists of three components: lipid produced by the Meibomian gland, aqueous produced by the lacrimal and accessory lacrimal glands, and mucin produced by goblet cells.Unbalance between those three layers can cause DES [1].DES can negatively affect the productivity of workers, especially office workers [3].In Saudi Arabia, DES is considered a highly prevalent and underdiagnosed disease [4][5].In Jeddah, a study of a 251 normal population, the prevalence of DES was 234 (93.2%) [5].On the other hand, in Al-Ahsa, a study of the 1858 population showed a prevalence of DES was 597 (32.1%) [6].Furthermore, another study in Saudi Arabia noted a defect in the knowledge and habits regarding DES; however, there was a small number of participants in the eastern region (17, 3.8%) [7].Considering the variability of the prevalence rate in Saudi Arabia and the lack of information about the knowledge of DES among the eastern province population, this study aims to establish reliable pieces of information regarding the awareness of dry eye syndrome among the eastern province population and to note whether we need to increase awareness in this region or not.

Methods
This is a descriptive community-based cross-sectional study based on a self-administer online questionnaire that evaluates the knowledge and awareness of dry eye among the eastern province population in Saudi Arabia.The data was collected by using a previously validated questionnaire by Khalid et al. [7].The sample size was calculated using the formula n = z2pq\d2.With a confidence level of 95%, an estimated proportion of 50%, and a 5% level of precision, the minimum sample size was calculated to be 385.The actual sample size was 522 participants.Inclusion criteria included all adults aged 18 years and above of both genders and living in the eastern province.Those who were below 18 years of age and not living in the eastern province were excluded.An online, self-administered questionnaire was distributed through social media.Five sections were included in the questionnaire; the first is a consent form to join the research; the second is related to demographic data; the third contains questions about past medical history.The fourth section includes questions about caring for eyes, and the fifth section questions assessing the awareness and knowledge regarding DES.

Data analysis
The data were collected, reviewed, and then fed to Statistical Package for Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY).All statistical methods were two-tailed with an alpha level of 0.05, considering significance if the P value was less than or equal to 0.05.Regarding participant awareness, each correct answer was given a 1-point score.Overall awareness level regarding dry eye disease was assessed by summing up discrete scores for different correct awareness items.If the total score was 60% or more of the total possible score, the level of awareness was considered good, and scores less than 60% were considered poor.Descriptive analysis was done by prescribing frequency distribution and percentage for study variables, including participant data, behavior, and practice.Also, participants' awareness of (DES) was tabulated while the overall awareness level was graphed.Cross tabulation was used to show participants' overall awareness level distribution by their data and other factors using the Pearson Chi-square test for significance and exact probability test if there were small frequency distributions.

Ethical consideration
After receiving participant consent to participate in the study, it will be conducted.The individual has the ability to withdraw at any point during the study as it is voluntary.No efforts are made to identify the subjects.The ethical clearance was given by the Deanship of Scientific Research at King Faisal University on September 13, 2022 (KFU-REC-2022-SEP-ETHICS166).

Results
A total of 522 participants fulfilling the inclusion criteria completed the study questionnaire.Participant's ages ranged from 18 to 65 years, with a mean age of 27.

TABLE 1 : Bio-demographic data of study participants in the Eastern region of Saudi Arabia
DM: Diabetes Mellitus; HTN: Hypertension

TABLE 3 : Population awareness regarding dry eye symptoms and risk factors in the Eastern region of Saudi Arabia
Moreover, 56 (50.0%) of healthcare workers/students had good awareness versus 93 (42.9%) nonemployed/non-healthcare worker participants (p=0.001).Good awareness was detected among 33 (40.2%) of those who had undergone eye surgery compared to 116 (26.4%) of others (p=0.011).Also, 12 (50.0%) of those who used ointments to moisturize the eyes had good awareness versus 32 (22.5%) of those who did not use any method (p=0.001).