Dry Eye Disease and Work Productivity Loss in Visual Display Users: The Osaka Study

MIKI UCHINO, YUICHI UCHINO, MURAT DOGRU, MOTOKO KAWASHIMA, NORIHIKO YOKOI, AOI KOMURO, YUKIKO SONOMURA, HIROAKI KATO, SHIGERU KINOSHITA, DEBRA A. SCHAUMBERG, AND KAZUO TSUBOTA To estimate the impact of dry eye disease (DED) on work performance and productivity in ofce workers using visual display terminals (VDTs).  DESIGN: Cross-sectional study.  METHODS: Six hundred seventy-two Japanese young and middle-aged ofce workers using VDTs completed a questionnaire that was designed to measured at-work performance decits and productivity losses using the Japanese version of the Work Limitations Questionnaire, completed by e-mail. Using the Japanese dry eye diagnostic criteria, respondents were classied into 3 groups: denite DED, probable DED, and non DED.  RESULTS: Of the 672 ofce workers, 553 subjects (82.3%), including 366 men and 187 women, completed the questionnaire and underwent clinical evaluation. As for the total workplace productivity loss, the non DED group demonstrated a loss of 3.56%, those with probable DED demonstrated a loss of 4.06%, and those with denite DED demonstrated a loss of 4.82%, indicating signicantly worse performance and productivity (P [ .014, trend test). For the 4 subscales, DED was associated with signicantly lower on-the-job time management (P [ .009, trend test) and combined mental performance and interpersonal functioning (P [ .011, trend test). After controlling for age, sex, VDT working hours, and diagnosis of DED, time management, physical demands, and mental and interpersonal functioning showed a signicant relationship to DED (each P > .05). Annual DED productivity losses were estimated to be $6160 per employee when measured by total production and $1178 per employee calculated by wage.
Accepted for publication Oct 23, 2013. From the Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan (M.U., Y.U., M.D., M.K., K.T.); the Ryogoku Eye Clinic, Tokyo, Japan (M.U.); the Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan (N.Y., A.K., Y.S., H.K., S.K.); the Moran Center for Translational Medicine, John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, University of Utah School of Medicine, Salt Lake City, Utah (D.A.S.); the Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts (D.A.S.); and the Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts (D.A.S.). The rst two authors contributed equally to this work. Inquiries to Miki Uchino, Department of Ophthalmology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; e-mail: uchinomiki@yahoo.co.jp  PURPOSE:  CONCLUSIONS:

This study indicated that there is a signicant impact of DED on the total productivity of Japanese VDT users. (Am J Ophthalmol 2014;157: 294300. 2014 by Elsevier Inc. All rights reserved.)
CCORDING TO THE INTERNATIONAL DRY EYE WORK

Shop, Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear lm instability with potential damage to the ocular surface.1 Dry eye disease (DED) is one of the most prevalent ocular surface diseases in the world, occurring from 4.4% to as high as 50% of middle-aged and older people.26 In the United States, estimates from the largest studies suggest that DED affects approximately 5 million people 50 years of age and older.5 Many studies have demonstrated that patients with DED experience an impact on their daily lives, including poorer general health among patients with moderate to severe DED.79 Prior studies also have demonstrated an impact of DED on the ability to work using questionnaires such as the Impact of Dry Eye on Everyday Life questionnaire, which includes a module on work productivity.1012 However, to the extent that this work is based on questionnaires developed for use specically in the dry eye setting, direct comparisons with other health conditions generally have not been performed. Whether one approach is better or worse has not, to our knowledge, been studied. Nonetheless, such work has aided the recognition that there is an economic burden from DED that can be divided into 2 categories: (1) direct costs such as medical fees and cost of medications and (2) indirect costs such as reduced employment rates, absence from work (absenteeism), and equivalent lost work days resulting from adversely affected performance (presenteeism).13 Moreover, there have been some studies using questionnaires, such as the Work Productivity and Activity Impairment Questionnaire, developed to assess work productivity across a range of health conditions that have reported a correlation between the severity of dry eye and the duration of both absenteeism and presenteeism, with perhaps a greater impact of DED on presenteeism.14,15 In Japan, Yamada and associates evaluated presenteeism in patients with DED using the Japanese version of the Work Limitations Questionnaire, an established tool for
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evaluation of presenteeism with high internal reliability.1619 However, that study was carried out as an online survey and did not include a clinical evaluation for DED, which could provide important additional information and may reduce misclassication. The present study was undertaken to address some of the limitations of prior studies. We evaluated the impact of DED on presenteeism in ofce workers using the Japanese version of the Work Limitations Questionnaire to allow for direct comparison of the impact of DED versus other health conditions. We conducted clinical evaluation and classication of DED according to the Japanese DED diagnostic criteria to address possible misclassication that could arise from use of self-reported DED.

evaluated by lissamine green and uorescein staining, after which assessment of tear lm break-up time was performed. Finally, the Schirmer test was performed for 5 minutes without topical anesthesia.
 WORK LIMITATIONS QUESTIONNAIRE:

METHODS
 SELECTION OF THE STUDY PARTICIPANTS:

This crosssectional study followed the tenets of the Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Ryogoku Eye Clinic, Tokyo, Japan. All subjects gave written informed consent. Under the supervision of the Japanese Dry Eye Society, the authors arbitrarily selected 2 large companies in the pharmaceutical company listed on the Japanese stock market. We sent a letter to the industrial physician of the health management section of each company to explain the purpose of the study and to request their participation. One company responded to our letter and consented to participate in this study. After an internal review of the protocol and the risks and benets of the study, permission was granted to conduct the study among employees who were willing to participate. Employees were invited by e-mail to answer the questionnaires and to attend a general ophthalmic check-up. A maximum of 2 e-mail reminders were sent. Subjects who reported a history of any eye surgery were excluded from the study protocol.

 DIAGNOSIS OF DRY EYE DISEASE:

The diagnosis of DED was established according to the Japanese DED diagnostic criteria.20 Briey, 3 criteria were evaluated: (1) presence of dry eye symptoms, (2) presence of qualitative or quantitative disturbance of the tear lm in one or both eyes _5 mm or tear lm break-up time (Schirmer test results < < _5 seconds), and (3) presence of conjunctival and corneal _3 points) in one or epithelial damage (total staining score, > both eyes. The presence of all 3 criteria was necessary for a denite diagnosis of DED. Subjects showing the presence of 2 of the 3 criteria were diagnosed with probable DED, whereas those with 1 or no positive criteria were diagnosed as having non DED.20 The methods for administration of Schirmer tests, tear lm break-up time analysis, and uorescein and lissamine staining have been documented previously.20 Corneal and conjunctival epithelial damage was

We used the Japanese version of the Work Limitations Questionnaire (Sompo Japan Healthcare Services, Inc, Tokyo, Japan). The questionnaire consists of 25 items and is a validated self-report survey tool for assessing the impact of health problems on at-work performance and productivity.1719 This tool uses data accumulated within a 4-week recall period and calculates scores ranging from 0 to 100 using a specic validated algorithm.1719 A score of 0 indicates no limitations, whereas a score of 100 indicates limitations 100% of the time. In addition to a total score that evaluated overall work performance, we also calculated subscale scores to evaluate 4 domains of work limitations: time management, physical demands, mental or interpersonal functioning, and output demands.1719 The time management scale contains 5 items that address difculty handling time and scheduling demands. The 6-item physical demands scale covers a persons ability to perform job tasks that involve bodily strength, movement, endurance, coordination, and exibility. The mental and interpersonal demands scale has 9 items addressing cognitive job tasks and on-the-job social interactions. The output demands scale contains 5 items concerning diminished work quantity and quality (eg, handling the workload and nishing work on time). Each question was evaluated using a 5-point scale (none of the time to all of the time). The nal scale score indicated the percent of time the patient was limited in performing the specic tasks of the job. Past or current history of certain common systemic diseases such as hypertension, diabetes mellitus, depression, and use of systemic medications was determined by asking participants whether they had ever been told that they had these conditions by their physicians or whether they used any systemic medications, including antidepressants. In addition to work limitation scores, we calculated the economic impact of work productivity losses in 2 ways: (1) based on average annual sales loss per person and (2) based on average annual wages per person. The data on the average annual sales per person as well as the average annual wage were provided by the participating company. Values in Japanese yen were converted to United States dollars using the currency exchange rate concurrent with the August 5, 2011, completion of the Osaka study (1 yen 0.0126 dollars).
 STATISTICAL ANALYSIS:

The analysis included all subjects who completed the Japanese version of Work Limitations Questionnaire and the dry eye clinical examination. Statistical comparisons of the total score, as well as the subscale scores, were made among the 3 DED diagnostic groups 295

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using the Dunnett test. Trend tests were performed via linear regression analysis to compare the degree of work performance loss as the outcome across the ordered groups indicating dry eye status (non DED, probable DED, denite DED). We then used multiple linear regression analysis to adjust for possible confounders (sex, age, and VDT hours). We categorized prolonged VDT working hours as more than 8 hours, because we previously showed this cut point was associated with DED.20 A P value of less than .05 was considered to indicate a statistically signicant difference. All statistical analyses were performed using the SAS software version 9.2 (SAS, Inc, Cary, North Carolina, USA).

Using models that evaluated the association between DED and work productivity losses after taking in account the possible inuence of other factors (age, sex, VDT hours), we observed a signicant association between DED and total productivity loss (P .022; Table 2). Additional adjustment for cigarette smoking (which was not associated with productivity loss; data not shown) did not affect ndings and was not included in the nal models. Considering the 4 subscales, 3 of them, time management, physical demands, and mental and interpersonal functioning, showed a signicant relationship with DED (P .021, P .023, and P .025, respectively). For the subscale of output demands, there was a borderline signicant association with DED (P .068). Absolute differences in work productivity loss comparing the DED versus non DED groups were 1.26% for the denite DED group and 0.5% for the probable DED group. At the participating company, the annual amount of sales per person was 38,650,000 yen ($488,869) and the average annual salary was 7,396,000 yen ($93,549). The estimated cost of annual work productivity losses per person was $6160 in the denite DED group and $2444 in the probable DED group. The total cost of their work productivity lost to the ofce is estimated at $1.38 million per year: denite DED probable DED, ($6160 per employee per year 3 11.8% of employees $2444 3 54.1%) 3 672 employees. Based on the average annual wage at the participating company, the estimated cost of annual work productivity loss was $1178 per employee with denite DED and $467 per employee with probable DED group. Using this model, the total economic impact for the company is estimated at $263,189: denite DED probable DED, ($1178 per employee per year 3 11.8% of employees $467 3 54.1%) 3 672 employees.
 ECONOMIC IMPACT:

RESULTS
 PARTICIPANTS AND DIAGNOSIS OF DRY EYE:

Of the 672 ofce workers in this company, 553 (82.3%) participated in this study, including 366 men (66.2%) and 187 women (33.8%) between 22 and 65 years of age. Using the Japanese DED diagnosis criteria,20 65 subjects (11.8%) were diagnosed with denite DED, 299 subjects (54.1%) were diagnosed with probable DED, and 189 subjects (34.2%) were in the non DED group. Characteristics of the study population are provided in Table 1 (detailed ophthalmic ndings were presented previously).20 Only 4.7% and 1.1% of all the subjects had hypertension or diabetes mellitus, respectively, with no signicant difference among the 3 DED groups (P .68 for hypertension and P .16 for diabetes mellitus). Previous studies showed an association between depression and DED;2124 however, only 2 subjects reported having been diagnosed with depression or to be using antidepressants in the current study. The degree of work limitation according to DED status was 4.82% in the denite DED group and 4.06% in the probable DED group; both showed greater losses than the non DED group (3.56%). There was a signicant difference between the denite DED and non DED groups (P .041; Figure 1). Using the average working hours in Japan (7.75 hours/day, 243 days/year), this difference can be converted to a loss of approximately 23.7 hours, or almost 3.1 working days in a year. The trend test across the 3 DED groups (non DED, probable DED, denite DED) also showed signicant worsening from the non DED to the denite DED group (P .014). Trend tests across DED diagnostic groups and each subscale score revealed 2 subscales that were signicantly lower in the denite DED group (P .009 for time management loss and P .011 for mental and interpersonal functioning loss; Figure 2). Subgroup analyses comparing subjects with (n 343) and without (n 21) dry eye symptoms showed a signicantly greater magnitude of work limitations among those with symptoms (4.33 6 3.44 vs 2.07 6 2.07; P .005).

 WORK LIMITATIONS:

DISCUSSION
OCCUPATIONAL MEDICINE OFTEN FOCUSES ON THE IMPOR-

tance and benets of addressing a variety of health issues in the workplace, such as cardiovascular disease, smoking, alcohol use, diabetes mellitus, and back problems, and this literature suggests that worksite health promotion programs could be successful in helping employees to reduce their health risks.2528 The present study demonstrated that DED is associated with a loss of work productivity. Using the Work Limitations Questionnaire, we estimated the loss at 4.82% in the denite DED group and 4.06% in the probable DED group, compared with 3.56% in the group without DED. We also found that the larger subset of DED subjects with symptoms had a signicantly greater impact on work productivity compared with asymptomatic DED subjects. Although these differences are of modest magnitude, they are statistically signicant FEBRUARY 2014

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TABLE 1. Characteristics of the Study Participants on Work Limitation Associated with Dry Eye Disease
Denite DED (n 65; 11.8%) Probable DED (n 299; 54.1%) Non DED (n 189; 34.2%) Total (n 553) P Value

Age (y) Male (%) Average VDT hours Hypertension, no. (%) Diabetes mellitus, no (%)

40.6 6 7.3 46.2 8.2 6 2.3 2 (3.1) 1 (1.5)

43.5 6 8.9 63.9 8.0 6 2.3 13 (4.3) 5 (1.7)

43.5 6 8.9 76.7 7.6 6 2.1 11 (5.8) 0 (0.0)

43.1 6 8.8 66.2 7.9 6 2.2 26 (4.7) 6 (1.1)

.045a,* .000b,* .071a .678b .164b

DED dry eye disease; VDT visual display terminal. Data are mean 6 standard deviation unless otherwise noted. *P < .05. a Analysis of variance. b Fisher exact test.

FIGURE 1. Bar graph showing work productivity loss by diagnosis of dry eye disease (DED) in the Osaka Study. The gure depicts the average productivity loss and its standard deviation for the denite dry eye group and probable dry eye group versus the no dry eye group. A trend test showed a signicant decrease among those classied as having dry eye disease. Also provided are P values based on pairwise comparisons of the 3 groups of subjects. *P < .05.

and translate into an estimated more than 3 work days of limitation per person per year. The magnitude of DED-related limitations are somewhat lower compared with data using the Work Limitations Questionnaire on the impact of some other health conditions.1012,1416 For example, associations between health problems and average work productivity losses have been estimated at: 7.9% for depression, 5.9% for osteoarthritis, 5.5% for back pain, 4.9% for migraine, 4.7% for u within the past 2 weeks, and 4.1% for allergies.29 However, because DED is so common, the overall impact is still substantial. Previous studies also have documented an adverse impact of DED on work productivity. For example, a cross-sectional study of 205 veterans showed that patients VOL. 157, NO. 2

with DED had a signicant loss in work productivity compared with the patients without DED.10 In another study, Abetz and gren syndrome-related associates found that patients with Sjo DED showed signicantly worse impact on work compared with normal and less severe DED.11 However, much of this work was performed using instruments such as the Impact of Dry Eye on Everyday Life questionnaire that were developed specically for use in the dry eye setting, and therefore does not allow for direct comparisons with effects of other health conditions. There have also been 2 prior studies that used a general productivity questionnaire. A study by Patel and associates, who used the Work Productivity and Activity Impairment Questionnaire in a cross-sectional, web-based survey administered to 9034 individuals 18 years of age or older,15 found that those with higher scores on the Ocular Surface Disease Index,30 a questionnaire concerning subjective symptoms of DED that has been used to grade the severity of DED, had a greater loss of work productivity.15 However, because this study did not include any subjects without DED, comparison of presenteeism against healthy individuals was not possible.15 Among 396 Japanese individuals 20 years of age or older, Yamada and associates demonstrated that work productivity in the group with self-reported DED was signicantly lower than that in a control group.16 However, this study was limited by a subjective assessment of DED and a low participation rate. Because our study used both symptom assessment and an objective evaluation of DED, it enabled us to evaluate the difference in work productivity between subjects with and without clinically diagnosed DED and to compare symptomatic and nonsymptomatic subjects (although the latter comparison was limited by the relatively small number of asymptomatic dry eye subjects). Our study also adds to the literature by controlling for possible confounders (age, sex, VDT hours), after which we continued to observe a signicant association between DED with work productivity loss. When work productivity loss was converted into an amount of money to estimate its economic impact, we identied losses for average sales revenue for the company of more than $6000 per employee per year for those with 297

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FIGURE 2. Work productivity loss associated with dry eye disease (DED) for the 4 Work Limitations Questionnaire subscale scores. Depicted are the means and standard deviation by dry eye status for each subscale: (Top Left) time management, (Top Right) physical demands, (Bottom left) mental or interpersonal, and (Bottom Right) output demands. A trend test showed a signicant decrease in the time management and output demands subscale scores across ordered DED groups. Also provided are P values based on pairwise comparisons of the 3 groups of subjects. *P < .01.

TABLE 2. The Adjusted Result of Workplace Productivity Loss in 4 Subscales: Dry Eye, Age, Gender, and Visual Display Terminal Working Hours
Total Loss Slope 6 SE P Value Time Management Loss Slope 6 SE P Value Physical Demands Loss Slope 6 SE P Value Mental or Interpersonal Loss Slope 6 SE P Value Output Demands Loss Slope 6 SE P Value

Dry eye 0.57 6 0.25 Age (y) 0.01 6 0.02 Gender (female) 0.10 6 0.34 VDT working hours 0.03 6 0.37 (>8 hours)

.022 .491 .768 .937

2.17 6 0.94 0.16 6 0.07 0.47 6 1.32 1.68 6 1.42

.021 .026a .722 .239

3.03 6 1.33 0.37 6 0.10 0.42 6 1.86 2.74 6 1.97

.023 .001b .819 .165

2.05 6 0.91 0.10 6 0.07 0.68 6 1.28 0.35 6 1.38

025 144 595 799

2.04 6 1.11 0.07 6 0.08 0.22 6 1.56 0.15 6 1.68

.068 .382 .889 .929

SE standard error; VDT visual display terminal. Adjusted for age, gender, and visual display terminal working hours of each group. a P < .05. b P < .01.

denite DED and nearly $2500 per employee per year for those with probable DED. This adds up to a total of $1.38 million in productivity loss per year because of DED at this ofce. Companies that understand how DED can be associated with productivity losses resulting in an economic impact may attach more importance to the diagnosis, treatment, and prevention of DED among their workers. To this 298

end, employers may be wise to implement educational and screening programs for their employees to prevent undiagnosed or misdiagnosed illnesses, allowing employees to manage their medical conditions better and to limit any impact on productivity. In addition to educational programs, it may be necessary for employers to improve the working environment to prevent the development of DED or to minimize its impact. FEBRUARY 2014

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The present ndings derive from responses of a group of ofce workers to the Work Limitations Questionnaire, a validated and well-characterized measure of job productivity, who also underwent clinical examination to determine their dry eye status. The ndings, however, should be interpreted in light of a number of study limitations. Representativeness is a concern because all study subjects were employees of a single company and no systematic criteria were used to select the company. In addition, the current study lacked information regarding other conditions that could inuence the association between DED and work limitations. For example, menopausal status and the use of postmenopausal hormone therapy, which previously was associated with DED,21 were not assessed in the Osaka Study. However, the prevalence of postmenopausal hormone therapy in Japan was low at the time of the survey (12.0% of women older than 50 years31), and in the study population, only 18 subjects were older than 50 years; both of these factors minimize any impact of this potential issue. Additionally, we found no signicant difference in the impact of DED on work limitations by gender. Similarly, depression was related to DED in prior studies, and antidepressants may increase risk of DED, but to the extent that DED also may increase the risk of depression,2124 it would be unclear whether depression might confound the association or alternatively might function as one mechanism through with DED could affect productivity. In Japan, the prevalence of depression is 2.2%;32 therefore, any potential misclassication would not be likely to reverse the observed association, although residual confounding remains possible. In addition, the Osaka Study did not collect information on the use of tear supplements or other therapies for DED. Use of such medications may have reduced DED symptoms, and the subjects using them therefore may have been misclassied as to

their true underlying DED status. We also could not perform analyses to determine whether such therapies might impact the relationship of DED with work productivity. However, to the extent that our study population reects the current management of DED in Japan, our results should estimate the impact of DED as it is managed (or not) on work productivity. Finally, this study is cross-sectional, and consequently we are unable to determine the long-term impact of DED on work productivity. The modest but signicantly greater magnitude of work limitations associated with DED is understandable in light of the ubiquitous use of computers in the workforce studied. This information should be of interest to industries and settings with high VDT demands on their workforce in light of the high prevalence of DED among VDT workers, which has been reported to be between 23%33 and 32.3% in Japan.34 Given the visual demands of VDT use and other ofce work, the decreased work performance we observed may be the result of alterations of higher-order aberrations35 and functional visual acuity,36 resulting in a decrease of reading speed,37 or secondary to a slower work pace resulting from ocular surface irritation. Many DED treatment protocols have been shown to improve these factors, suggesting that treatment of DED may have a benecial impact on work productivity, although this has not yet been shown scientically. In summary, this study revealed that DED status, as assessed by clinical DED evaluation, is associated with lower work productivity and impaired work performance in relatively young VDT users. DED is a relatively common and treatable chronic disease in the employed population. Our ndings suggest that disease management programs may present an opportunity to enhance the quality of life of DED patients and, at the same time, potentially may limit losses in on-the-job productivity.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST and the following were reported. Norihiko Yokoi is a consultant for Kissei Co, Ltd, and Rohto Co, Ltd. Shigeru Kinoshita is a consultant for Santen Pharmaceutical Co, Ltd, and Otsuka Pharmaceutical Co, Ltd. Debra A. Schaumberg is a consultant for Eleven Biotherapeutics, Pzer, Inc, Alcon, Inc, Allergan, Inc, Inspire Pharmaceuticals, and Resolvyx. Kazuo Tsubota is a consultant for Santen Pharmaceutical Co, Ltd, Acu Focus, Inc, Bausch Lomb Surgical, Pzer, Thea. The remaining authors have no relationships to disclose. Provision of facilities, transport of equipment, data analysis, and data management were supported by Santen Pharmaceutical Co., Ltd, Osaka. The funding organization had no role in the design or conduct of this research. This study was supported by the Ministry of Education, Science, Sports and Culture, Grant-in-Aid 2279192 (2010) for Young Scientists (B) in Japan. Involved in conception and design of study (M.U., Y.U., N.Y., M.D., M.K., S.K., D.S., K.T.); Analysis and interpretation of data (M.U., Y.U., M.D., D.S.); Writing article (M.U., Y.U., N.Y., M.D., M.K., D.S.); Data collection (M.U., Y.U., N.Y., M.D., M.K., A.K., Y.S., H.K.); Provision of materials, patients, or resources (M.U., Y.U., N.Y., M.D.); Statistical expertise (M.U., Y.U., N.Y., D.S.); Literature search (M.U., Y.U., N.Y., M.D., D.S.); Administrative, technical, or logistic support (M.U., Y.U., N.Y., M.D., M.K., S.K., D.S., K.T.); Critical revision of article (M.U., Y.U., N.Y., M.D., D.S.); and Final approval of article (M.U., Y.U., N.Y., M.D., M.K., A.K., Y.S., H.K., S.K., D.A., K.T.).

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