Dry Eye Disease and Contact Lens Use: Assessing Awareness, Knowledge, and Self-Care Behaviors in the Saudi Population

A frequent multifactorial condition of the ocular surface, dry eye disease (DED) can have a substantial impact on comfort and vision. DED is described as a "multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles" by the Tear Film and Ocular Surface Dry Eye Workshop II (TFOS DEWS II) [1].

The prevalence of DED varies across different regions, ranging from 4.6% in North America to 47.9% in Africa [2]. In Asian countries, approximately 20.1% of individuals develop DED. Moreover, in some industrialized Asian countries, such as Taiwan, Korea, and Japan, over a quarter of the population is affected [3]. The population of Saudi Arabia, particularly in the eastern province, is very susceptible to acquiring DED because of the region's epidemiological and environmental risk factors. The eastern province, like the majority of Saudi Arabia, is noted for having one of the warmest desert climates, with summertime highs over 50 degrees, which is a significant risk factor for DED [4].

The development of DED is also greatly influenced by environmental factors, such as air pollution, climate, and the usage of digital devices. Temperature, humidity, and air pollutants have a major impact on tear film stability and ocular surface health worldwide, according to a thorough review [5]. In controlled trials, low relative humidity has been repeatedly linked to increased tear evaporation, decreased tear stability, and worsening symptoms of DED [6]. A recent systematic review and dose-response meta-analysis by Ha et al. found that every additional hour of daily digital screen time was linked to 21% higher odds of myopia. This relationship followed a sigmoidal pattern, suggesting potential harm beyond one hour of daily exposure. The widespread use of digital devices has also emerged as a significant risk factor [7].

Tear film instability, hyperosmolarity, and ocular surface inflammation brought on by a lack of homeostasis are the hallmarks of DED. Neuropathic ocular pain (NOP) can arise from peripheral and central sensitization, neuronal plasticity, and corneal nerve damage [8]. Early on, subclinical inflammation that may go unreported is frequently present along with symptoms that are temporary and reversible. However, more serious illness, characterized by permanent epithelial alterations, chronic inflammation, and visual impairment, may arise if the ocular surface is unable to re-equilibrate [9].

Therefore, decreased tear flow, increased evaporation, and repetitive nerve stimulation can cause DED to develop into an irreversible chronic condition if treatment is not received. Treatment-resistant illness and irreversible damage to the ocular surface result from this self-sustaining cycle of inflammation [10]. Significant clinical problems are presented by the variety in disease development and the complexity of DED presentations. To end the disease's vicious cycle, treatment plans must concentrate on preserving and restoring ocular surface homeostasis [11].

Wearing contact lenses has been identified as a modifiable risk factor for DED, and dryness from the lenses is frequently mentioned as the main reason for pain, shorter wearing times, and lens cessation. Dry eye symptoms are thought to affect between 15% and 55% of contact lens wearers, which is higher than the percentage seen in non-contact lens wearers [1]. Increased tear film instability brought on by contact lens friction with the ocular surface, accelerated pre-corneal tear film evaporation and subsequent tear film thinning, decreased contact lens wettability, ocular surface inflammation, and meibomian gland dysfunction are some of the hypothesized mechanisms of contact lens-related dry eye [12].

The current study aimed To assess awareness, knowledge, and self-care behaviors regarding DED among contact lens users in Saudi Arabia, and examine the relationship between lens-wearing habits and symptom severity.. In addition, potential risk factors, including age, sex, contact lens type, duration of contact lens wear, and contact lens care practices) were examined to evaluate their statistical association with DED symptoms. The results of this study are intended to increase knowledge of symptomatic DED in contact lens wearers and to aid in the creation of methods to lessen discomfort and lower the region's contact lens dropout rates.

Study Design and Setting

This was a cross-sectional study conducted between July 2025 to May 2026 in Saudi Arabia. The study used a structured questionnaire developed by the authors based on previous literature to assess the relationship between dry eye disease and awareness and self-care practices among contact lens users. The study targeted the Saudi population of both males and females across different age groups that wear contact lenses.

Sample Size

To make sure there were enough responses for the sample to be representative of the entire population, the sample size was calculated. The Raosoft sample size calculator was used to calculate the sample size. The computed sample size was 384 with an indicator percentage of 0.50, a 5% margin of error, and a 95% confidence interval (CI).

Inclusion Criteria

Included adults aged 18–65 years who were healthy, currently residing in Saudi Arabia, and actively using contact lenses (daily, weekly, or monthly disposable lenses). Eligible participants were required to provide informed consent and report symptoms suggestive of dry eye disease (DED) or related ocular discomfort.

Exclusion Criteria

included individuals who had undergone ocular surgery within the previous six months, had an active ocular surface disease, were not contact lens users, or provided incomplete responses to key survey items. Participants with coexisting ocular conditions, complicated or severe dry eye disease, or autoimmune disorders known to affect tear production or ocular surface health—such as Sjögren’s syndrome, rheumatoid arthritis, systemic lupus erythematosus, ocular graft-versus-host disease, or Stevens–Johnson syndrome—were also excluded from the study.

Method for Data Collection, Instrument

A structured questionnaire was used as the study tool. The instrument was developed in both Arabic and English after reviewing relevant literature and adapting items from validated surveys related to dry eye symptoms and contact lens use within the Saudi population. The final version of the questionnaire consisted of 16 questions divided into three main sections.

• The First Section: included sociodemographic characteristics such as gender, age group, and educational level
• The Second Section: assessed participants’ knowledge and experiences regarding dry eye symptoms. This included questions about the presence and frequency of symptoms, use of eye drops or other treatments, perceived causes and risk factors, and types of treatments used
• The Third Section: contained perception and practice-related questions, including the effect of dry eye symptoms on daily activities, frequency and duration of contact lens use, discomfort while wearing lenses, experience with therapeutic lenses, and reasons for discontinuing their use

The questionnaire was self-administered and distributed online through a secure survey platform. It required approximately 5–10 minutes to complete. Participation was voluntary, and informed consent was obtained electronically before proceeding. Data collection was conducted among residents of Saudi Arabia to ensure the target population was appropriately represented.

Scoring System

Dry Eye Symptom Score (DESS):

The Dry Eye Symptom Score is calculated based on responses to questions 4 through 9 and questions 10 through 15, with each item scored on a scale from 0 to 3. The maximum possible score is 30. The total score is interpreted as follows: a score between 0 and 6 indicates no or minimal symptoms; 7 to 14 reflects mild symptoms; 15 to 22 represents moderate symptoms; and 23 to 30 indicates severe symptoms. This score provides a quantitative measure of the severity of dry eye symptoms experienced by the individual.

Contact Lens Discomfort Score (CLDS)

The Contact Lens Discomfort Score is derived from questions 17, 18, 19, and 21. Question 17 evaluates the number of hours contact lenses are worn daily, with scores assigned as follows: less than 4 hours = 0, 4 to 8 hours = 1, and more than 8 hours = 2. Question 18 assesses the level of discomfort experienced while wearing contact lenses on a scale of 0 to 3. Question 19 asks whether the participant has stopped using lenses due to discomfort, scored as 0 for “No” and 2 for “Yes.” Question 21 measures comfort with therapeutic lenses, with responses scored as follows: very comfortable = 0, comfortable = 1, uncomfortable = 2, and very uncomfortable = 3. The total CLDS ranges from 0 to 9. Interpretation of the final score is as follows: a score between 0 and 2 indicates comfort with contact lenses; a score of 3 to 5 suggests moderate discomfort; and a score of 6 to 9 signifies severe discomfort.

Pilot Test

This Questionnaire was Distributed on 20 Individuals and asked to Fill it. This was done to Test the Simplicity of the Questionnaire and the Feasibility of the Study. Data of the Pilot Study Will Excluded from Fhe Final Data of the Study.

Analyzes and Entry Method

The data had been entered into the device using the "Microsoft Office Excel Software" Windows (2021). The collected data were subsequently transmitted to the Statistical Package of Social Science Software (SPSS) application, version 26 (IBM SPSS Statistics for Microsoft Windows, Version 21.0) for statistical analysis. Descriptive statistics were used to summarize the numerical variables for baseline characteristics. For categorical variables, frequencies and percentages were calculated. The Chi-square test was used to identify associations between categorical variables.

Table 1 shows the sociodemographic characteristics of the studied participants, this study included 518 participants. The mean age was 35.17±14.504 (18-65). The majority of patients were females (282, 59.5%), married (241, 50.8%), living in Western region (361, 76.2%) and Bachelor degree (256, 54%).

Table 1: Sociodemographic Characteristics of the Studied Participants (n = 518)

In Table 2 The results in table 2 showed a high prevalence of dry eye symptoms among participants, with over half (51.1%) reporting experiencing symptoms such as burning or itching. most participants reported experiencing dryness, discomfort during screen use, once or twice a day. screen exposure was as the most common aggravating factor (73.6%), followed by exposure to wind or dry environments (52.1%), revealing the role of environmental and lifestyle influences. only about half of participants reported using eye drops (49.2%), lubricating drops were the most commonly used treatment among users (87.6%).

Table 2: Distribution of Knowledge of Dry Eye Symptoms (N = 474)

The participants in Table 3 showed that Dry Eye Disease slightly affects their daily activities (49.8%), while only 6.5% reported severe effect. Cosmetic contact lens use showed (29.5%) predominately using from less than 4 hours (44.6%, and from 4 -8 hours with 44.1%), discomfort was noticed, with 41% showed sometimes feel discomfort. Majority of the participants had not tried therapeutic lenses (90.3%), and among those who did, about half reporting comfort to some extent (51%). 27.5% of participants stopped using therapeutic lenses due to discomfort, and 47.7% of users discontinued cosmetic lenses due to discomfort, and most could tolerate lenses for less than 4 hours. Participants who consulted eye specialist represented 37.6%, and the majority of participants 65.2% liked to participating in future studies, indicating a positive opportunity for awareness and intervention programs.

Table 3: Perception and Practice of Participants Regarding Dry Eye Disease and Contact Lens Use

Moderate to severe represented about 38.3%, while mild and minimal were 61.7% (Table 4, Figure 1).

Figure 1: Distribution of DESS levels

Table 4: Distribution of Dry Eye Symptom Score (DESS) Levels (n = 316)

The chi-square analysis showed that DESS severity was significantly associated with education level (χ² = 42.901, df = 24, p = 0.010), with the majority of participants holding a bachelor’s degree. No statistically significant associations were observed between DESS severity and age groups (p = 0.353), marital status (p = 0.519), residential area showed significant association with higher proportions in Western (p = 0.003). Gender showed a significant association with DESS severity (χ² = 17.832, df = 3, p<0.001), females showed higher proportion than males, revealing a higher symptom severity among females in Table 5.

Table 5: Association between Dry Eye Symptom Score (DESS) Severity and Demographic Factors of the Studied Participants

In Table 6 There was a statistically significant association between DESS severity level and wearing cosmetic contact lens use (χ² =14.314, p = 0.003), indicating that higher severity of dry eye symptoms was more common among contact lens users. No significant association was found between DESS severity and daily duration of contact lens wear (χ²=5.960, p = 0.428), but wearing contact lenses for 4-8 hours showed higher percentage in in severe and moderate DESS levels, and for more than 8 hours showed higher in moderate level.

Table 6: Association between DESS Severity and Contact Lens use among Participants

In Table 7 The results indicate that education level is the only variable significantly associated with CLDS score (χ² = 25.207, df = 10, p = 0.004). Participants with a bachelor’s degree constituted the largest proportion of those reporting moderate discomfort (63.8%), and severe discomfort in 22.2%. no statistically significant associations were observed between CLDS score and age groups (p = 0.281), gender (p = 0.876), marital status (p = 0.759), or residential area (p = 0.213). Although younger participants (18–29 years) represented the largest proportion across all CLDS categories, and females showed slightly higher proportions of discomfort compared to males.

Table 7: Association between Total CLDS Score and Sociodemographic Characteristics Using Chi-Square and Monte Carlo Test

Figure 2: Distribution of Contact Lens Discomfort Score (CLDS) (n = 76)

Moderate to severe discomfort represent 73.6%

Inflammatory diseases of the ocular surface and ocular pain or visual symptoms are linked to a set of tear film disorders known as "dry eye disease,"(DED) which are caused by decreased tear film production or instability. Dry eye illness is a developing public health issue that impairs quality of life, including aspects of everyday activities, employment productivity, and social, psychological, and physical functioning. It causes ocular discomfort, weariness, and visual disruption [13]. The current study aimed to assess awareness, knowledge, and self-care behaviors regarding DED among contact lens users in Saudi Arabia, and examine the relationship between lens-wearing habits and symptom severity.

Regarding sociodemographic characteristics of the studied participants, this study included 518 participants. The mean age was 35.17±14.504 (18-65). The majority of patients were females (282, 59.5%), married (241, 50.8%), living in Western region (361, 76.2%) and Bachelor degree (256, 54%). The chi-square analysis showed that DESS severity was significantly associated with education level (χ² = 42.901, df = 24, p = 0.010) and gender (χ² = 17.832, df = 3, p<0.001), while there was no significant association with age (p = 0.353) and marital status (p = 0.519).

Previous research has identified gender and age as significant factors in DED prevalence [14,15]. In our study, gender showed a significant association with DESS severity (χ² = 17.832, df = 3, p<0.001), females showed higher proportion than males, revealing a higher symptom severity among females but there were no statistically significant associations observed between DESS severity and age groups. Alharbi et al found that females were more likely to develop DED, with 73% of females reporting DED compared to 57.4% of males (p = 0.003). Additionally, older participants were more likely to experience DED; specifically, 76.9% of participants over 55 years had DED compared to 69.4% of those aged 19-25 [16]. Different studies found increased DED incidence among females and older individuals [17,18]. While some studies have reported no significant gender differences or a higher prevalence in younger populations [19, 20].

In our study we discovered that 140 (29.5%) of participants wear cosmotic contact lenses and 46 (9.7%) wear therapeutic lenses. There was a statistically significant association between DESS severity level and wearing cosmetic contact lens use (χ² = 14.314, p = 0.003), indicating that higher severity of dry eye symptoms was more common among contact lens users. Adversely contact lenses were not determined to be a significant risk factor for dry eye syndrome by Helayel et al., possibly due to other reasons like hot and dry weather, which makes the statistics for CL inconsequential [20]. Moreover, 41 % feel dry eye symptoms while wearing contact lenses, compared to the 4.5% reported severe dry eyes in a study conducted in the Asir Region [21].

A high prevalence of dry eye symptoms was found among participants, with over half (51.1%) experienced symptoms such as burning or itching and dryness. According to Dry Eye Symptom Score (DESS) 61.7 % of patients experienced minimal to mild symptoms while 38.3 % experienced moderate to severe symptoms. This prevalence is higher than that reported in some previous studies in Saudi Arabia, such as a prevalence of 38.4% [20] , 32.1% in Al-Ahsa [15], and 49.5% among 4,066 healthy adults from five regions [18]. However, our findings were lower than that of two studies, the first one of an urban population in high-altitude areas of Southwest Saudi Arabia, where the prevalence was 66.8% [22], and a broader study that reported a DED prevalence of 74.9% across various regions of Saudi Arabia [23].

Most participants reported experiencing dryness, discomfort during screen use, once or twice a day. screen exposure was as the most common aggravating factor (73.6). This is comparable to the findings of Kalakattawi et al, who discovered that the majority of her sample (86.5%) spent a significant amount of time each day watching TV and using computers or mobile phones [24]. The majority of research indicates that people with DES frequently complain of eye strain, eye tiredness, burning, redness, dry eye, and blurred vision when they watch TV or other electronic devices without taking breaks [25]. The study's findings regarding the practice of prolonged electronic device viewing are unrelated to general knowledge, although most participants were aware that this behavior could lead to DES and that quitting or taking a break could help. But they had it. As a result, we discovered that different populations have different attitudes and levels of knowledge.

This study indicates a considerable prevalence of Dry Eye Disease (DED) symptoms in the Saudi population, with over half of the participants reporting at least one symptom and a notable number experiencing moderate to severe cases. The use of cosmetic contact lenses was widespread and showed a strong correlation with increased severity of dry eye symptoms, indicating that wearing these lenses may worsen or lead to dry eye issues. Females exhibited notably higher DESS severity than males. Additionally, there were significant association with education level and residential area, suggesting that sociodemographic factors may impact the burden of the disease and awareness of it. While most participants indicated that their symptoms had a mild effect on their daily activities, a significant number faced functional limitations, stopped using contact lenses because of discomfort, and made limited use of therapeutic treatments. The low use of therapeutic contact lenses and the average frequency of consultations with eye care professionals suggest a lack of awareness and effective management practices. The results highlight the importance of specific public health approaches to enhance awareness, early detection, and suitable self-care methods for dry eye disease, especially for those who use contact lenses.

Limitations of the Study

• The cross-sectional design limits the ability to establish causal relationships between contact lens use and dry eye severity
• Using self-reported questionnaire data may lead to inaccuracies in remembering and reporting, especially when evaluating how often symptoms occur and habits related to wearing contact lenses
• The sample mainly includes younger adults and those with higher levels of education, which could restrict the ability to apply the findings to the overall Saudi population, especially older individuals or those with lower educational attainment
• Dry eye disease was not clinically confirmed, and the classification of its severity was based on questionnaire scores instead of objective eye examinations. This approach may result in misclassification bias

Acknowledgements We acknowledge all volunteers who provided samples for this research.

Ethical Approval

The study was fully explained to all participants, and it was emphasized that participation was voluntary. Written informed consent was obtained from each participant prior to enrollment. All collected information was securely stored and used exclusively for research purposes.

Funding This study did not receive any funding from public, commercial, or non-profit funding agencies.

Conflict of Interest

The authors declare that there are no conflicts of interest.

Informed Consent

Written informed consent was obtained from all study participants.

Data and Materials Availability

All data generated or analyzed during this study are included in this published article.

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