Shouldn’t Americans, collectively through our federal agencies, invest more each year to protect our eye health than most people spend on a single cup of coffee? Elected officials could make that a reality by allocating more federal funds to the National Eye Institute (NEI) for much-needed research. And insufficient awareness of eye diseases, particularly dry eye, demands greater attention from those who serve the public good.

That’s the pitch Congressional representatives heard Wednesday from prominent stakeholders in eye care. Members of the Tear Film & Ocular Surface Society (TFOS) and the Alliance for Eye and Vision Research (AEVR) were on hand in Washington, DC, to present data to legislators both publicly and privately. 

Follow the Money

AEVR notes that the direct medical costs of vision disorders are the fifth highest in the nation, tallying an annual cost of $145 billion in 2014 that’s projected to grow to $373 billion by year 2050. But the NEI’s 2017 budget of $733 million amounted to just 0.5% of that $145 billion price tag. The United States spends $2.30 per person annually for vision research, while the cost of treating low vision and blindness is $6,680 per person per year.

One-on-one meetings of TFOS and AEVR with the offices of Senators Edward Markey (D-Mass) and Elizabeth Warren (D-Mass) emphasized the value of NEI research and urged them to support the Senate’s proposed $27 million boost in NEI funding for 2019—a threefold increase over the House’s proposed $9.2 million. “Both senators’ offices are very supportive of the healthcare funding and increasing the research because they realize how imperative it is to improve the lives of many millions of sufferers,” said TFOS Executive Director Amy Gallant Sullivan. “Dry eye disease is omnipresent and we need to address it now.”

To stress that investment in NEI is money well spent, legislators were briefed on previous NEI-funded success stories that yielded cost savings and productivity improvements, in addition to their positive impact on health and quality of life. The development of OCT, anti-VEGF injections, the AREDS vitamin formulation, glaucoma drugs, improvements to cataract surgery and many others all benefited from NEI’s work, AEVR noted.

Dr. Sullivan, founder of TFOS, explained the group's efforts to understand dry eye and create effective treatment protocols for it to an audience of legislative aides in Washington, DC, on July 11.

Spreading the Word

A public forum held with legislative aides of numerous representatives detailed many aspects of eye health and dry eye that resonate with the public, including digital device use, contact lens wear and the contribution of eye cosmetics and systemic sources to dry eye’s footprint.

TFOS founder David Sullivan, PhD, of Harvard’s Schepens Eye Research Institute began the session by laying out the extent of the problem: more than 30 million Americans suffer from dry eye, and it’s the leading cause of patient visits to eye care practitioners. Dry eye’s burden on the US healthcare system is estimated to be $3.84 billion, Dr. Sullivan noted, while total societal cost exceeds $55 billion because of diminished productivity.

He also sketched out, in simple terms, the model of dry eye pathogenesis recently detailed in the TFOS Dry Eye Workshop II (DEWS II) report as a foundation for the more detailed presentations that came next.

Dr. Sullivan was followed by Janine Austin-Clayton, MD, the National Institutes of Health’s associate director for Research on Women’s Health, who updated the audience on systemic diseases linked to dry eye, in particular autoimmune conditions such as rheumatoid arthritis, lupus and Sjögren’s syndrome. “All affect many, many more women than men,” she stressed, reminding the group that the dry eye population is roughly two-thirds female. Genetic predispositions and differing immune responses probably account for the male-female differential, she explained.

Next, Penny Asbell, MD, professor of ophthalmology at New York’s Mt. Sinai hospital, addressed contact lens wear and ocular surface health. More than 50% of contact wearers have dry eye, compared with just 22% of non-users, she said, noting that an explanation for the distinction remains elusive. Do contact lenses cause dry eye, she wondered, or is there an underlying disease present that is activated by lens wear? Dr. Asbell also explained the somewhat disappointing findings of the recent DREAM study of omega fatty acids. She concluded with a brief summary of keratoconus and called out the “epidemic” of myopia. The condition needs to be recognized as a disease, not merely a refractive error, she suggested. “The patients themselves don’t feel that way,” she observed.

FDA regulation of cosmetics is long overdue for an overhaul to protect patients from harmful chemicals that contribute to dry eye, said Leslie O'Dell, OD, at the briefing.

Leslie O’Dell, OD, of Wheatlyn Eye Care in York, PA, presented on cosmetics and ocular surface disease, noting that women on average expose themselves to 167 chemicals during a typical beauty regimen. Cosmetic products are regulated under a statue that has not been updated in 80 years. The United States, she noted, bans just 11 chemicals from cosmetics, while the European Union prohibits 1,328 agents. She urged the legislators present to support legislation proposed by Senators Dianne Feinstein (D-CA) and Susan Collins (R-ME) that would increase FDA scrutiny and require manufacturers to register ingredients of personal care products and any known adverse reactions with the agency.

Scott Schachter, OD, of Pismo Beach, Calif. concluded the presentations with a discussion of digital device use, pointing out that 83% of Americans use a device at least two hours per day and 60% report symptoms of eyestrain as a result. Blink quality and frequency are both impaired by device use, he explained. Dr. Schachter also cited alarming statistics about pervasive screen use among young children, with one study showing that 68% of three-year-olds were regularly using a digital device. “These devices are the babysitters of today,” he said, holding up a phone.

Next Steps

The briefing concluded with a panel discussion and wish list of sorts for NEI-funded research the presenters hoped to see in the future. Dr. Asbell proposed greater study into minimally invasive biomarkers of dry eye that would help clinicians quantify the effect of treatment. Dr. Schachter, noting that a ‘cure’ for dry eye isn’t possible, advocated for better preventive care strategies, while Dr. O’Dell lobbied for greater attention to iatrogenic effects of cosmetic products and other external influencers.

Will the day’s blitz of Capitol Hill education on complex medical topics gain traction with busy legislators? Ms. Sullivan, of TFOS, is optimistic that they’ll see the value. “If you can actually diminish the suffering of dry eye patients,” she said, “you will increase the economy, increase production and improve quality of life” simultaneously.

The TFOS DEWS II study educated the healthcare community about the so-called vicious circle of dry eye, in which ocular surface stress degrades the tear film, leading to hyperosmolarity and inflammation that exacerbate tear instability, which then perpetuates the cascade. Fitting, then, that the antidote could be an inversion of that—a virtuous circle, in which investment in more eye research yields healthcare improvements that reduce costs, freeing up funding for a sustained long-term effort to support eye research and the manifold benefits it confers on individuals and society.