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Dry eyes

Roni M Shtein, MD
Section Editor
Jonathan Trobe, MD
Deputy Editor
Lee Park, MD, MPH


Dry eye disease is a multifactorial disease of the tears and ocular surface that can result in ocular discomfort and visual impairment [1]. Dry eye is also known as keratoconjunctivitis sicca, dry eye syndrome, and dysfunctional tear syndrome.

The epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment options for dry eye will be reviewed here. Various conditions associated with dry eye are discussed separately. (See "Diagnosis and classification of Sjögren's syndrome" and "Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Blepharitis".)


Prevalence — The exact prevalence of dry eye disease is unknown due to the difficulty in defining the disease and the lack of a single diagnostic test to confirm its presence. Based on self-report of dry eyes in the Beaver Dam Offspring cohort, prevalence of dry eye was reported as 14.5 percent (17.9 percent in women and 10.5 percent in men) [2]. Other studies have estimated prevalence at 5 to 30 percent of the population age 50 years and over [3-5]. This prevalence is expected to increase as the population in developed countries continues to age.

Risk factors — Risk factors for dry eye disease include [6-9]:



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Literature review current through: Sep 2016. | This topic last updated: Dec 22, 2015.
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  1. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:75.
  2. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol 2014; 157:799.
  3. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:93.
  4. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000; 118:1264.
  5. Ezuddin NS, Alawa KA, Galor A. Therapeutic Strategies to Treat Dry Eye in an Aging Population. Drugs Aging 2015; 32:505.
  6. Santaella RM, Fraunfelder FW. Ocular adverse effects associated with systemic medications : recognition and management. Drugs 2007; 67:75.
  7. Jaenen N, Baudouin C, Pouliquen P, et al. Ocular symptoms and signs with preserved and preservative-free glaucoma medications. Eur J Ophthalmol 2007; 17:341.
  8. Gilbard JP. The diagnosis and management of dry eyes. Otolaryngol Clin North Am 2005; 38:871.
  9. Latkany R. Dry eyes: etiology and management. Curr Opin Ophthalmol 2008; 19:287.
  10. Moutsopoulos HM, Manoussakis MN. Immunopathogenesis of Sjogren's syndrome: "facts and fancy". Autoimmunity 1989; 5:17.
  11. Pflugfelder SC. Prevalence, burden, and pharmacoeconomics of dry eye disease. Am J Manag Care 2008; 14:S102.
  12. Schiffman RM, Walt JG, Jacobsen G, et al. Utility assessment among patients with dry eye disease. Ophthalmology 2003; 110:1412.
  13. Buchholz P, Steeds CS, Stern LS, et al. Utility assessment to measure the impact of dry eye disease. Ocul Surf 2006; 4:155.
  14. Reddy P, Grad O, Rajagopalan K. The economic burden of dry eye: a conceptual framework and preliminary assessment. Cornea 2004; 23:751.
  15. Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye disease in the United States: a decision tree analysis. Cornea 2011; 30:379.
  16. Stern ME, Beuerman RW, Fox RI, et al. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea 1998; 17:584.
  17. Li DQ, Chen Z, Song XJ, et al. Stimulation of matrix metalloproteinases by hyperosmolarity via a JNK pathway in human corneal epithelial cells. Invest Ophthalmol Vis Sci 2004; 45:4302.
  18. Damato BE, Allan D, Murray SB, Lee WR. Senile atrophy of the human lacrimal gland: the contribution of chronic inflammatory disease. Br J Ophthalmol 1984; 68:674.
  19. Gilbard JP, Gray KL, Rossi SR. A proposed mechanism for increased tear-film osmolarity in contact lens wearers. Am J Ophthalmol 1986; 102:505.
  20. Kaiserman I, Kaiserman N, Nakar S, Vinker S. Dry eye in diabetic patients. Am J Ophthalmol 2005; 139:498.
  21. Tsubota K. Tear dynamics and dry eye. Prog Retin Eye Res 1998; 17:565.
  22. Bron AJ, Tiffany JM, Gouveia SM, et al. Functional aspects of the tear film lipid layer. Exp Eye Res 2004; 78:347.
  23. Lemp MA. Report of the National Eye Institute/Industry workshop on Clinical Trials in Dry Eyes. CLAO J 1995; 21:221.
  24. Belmonte C, Acosta MC, Gallar J. Neural basis of sensation in intact and injured corneas. Exp Eye Res 2004; 78:513.
  25. Nichols KK, Mitchell GL, Zadnik K. The repeatability of clinical measurements of dry eye. Cornea 2004; 23:272.
  26. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea 2004; 23:762.
  27. Begley CG, Chalmers RL, Abetz L, et al. The relationship between habitual patient-reported symptoms and clinical signs among patients with dry eye of varying severity. Invest Ophthalmol Vis Sci 2003; 44:4753.
  28. Montés-Micó R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg 2007; 33:1631.
  29. Liu Z, Pflugfelder SC. Corneal surface regularity and the effect of artificial tears in aqueous tear deficiency. Ophthalmology 1999; 106:939.
  30. Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:108.
  31. Lemp MA, Bron AJ, Baudouin C, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol 2011; 151:792.
  32. Sullivan BD, Whitmer D, Nichols KK, et al. An objective approach to dry eye disease severity. Invest Ophthalmol Vis Sci 2010; 51:6125.
  33. Hesse L. Intravitreal injection of tissue plasminogen activator: four considerations. Arch Ophthalmol 2001; 119:456.
  34. Rajagopalan K, Abetz L, Mertzanis P, et al. Comparing the discriminative validity of two generic and one disease-specific health-related quality of life measures in a sample of patients with dry eye. Value Health 2005; 8:168.
  35. Rubin GS, West SK, Muñoz B, et al. A comprehensive assessment of visual impairment in a population of older Americans. The SEE Study. Salisbury Eye Evaluation Project. Invest Ophthalmol Vis Sci 1997; 38:557.
  36. Laflamme MY, Swieca R. A comparative study of two preservative-free tear substitutes in the management of severe dry eye. Can J Ophthalmol 1988; 23:174.
  37. Drugs for some common eye disorders. Treat Guidel Med Lett 2010; 8:1.
  38. Nilforoushan MR, Latkany RA, Speaker MG. Effect of artificial tears on visual acuity. Am J Ophthalmol 2005; 140:830.
  39. Willen CM, McGwin G, Liu B, et al. Efficacy of cyclosporine 0.05% ophthalmic emulsion in contact lens wearers with dry eyes. Eye Contact Lens 2008; 34:43.
  40. Huang FC, Tseng SH, Shih MH, Chen FK. Effect of artificial tears on corneal surface regularity, contrast sensitivity, and glare disability in dry eyes. Ophthalmology 2002; 109:1934.
  41. Bron AJ, Mangat H, Quinlan M, et al. Polyacrylic acid gel in patients with dry eyes: a randomised comparison with polyvinyl alcohol. Eur J Ophthalmol 1998; 8:81.
  42. Brodwall J, Alme G, Gedde-Dahl S, et al. A comparative study of polyacrylic acid (Viscotears) liquid gel versus polyvinylalcohol in the treatment of dry eyes. Acta Ophthalmol Scand 1997; 75:457.
  43. Lenton LM, Albietz JM. Effect of carmellose-based artificial tears on the ocular surface in eyes after laser in situ keratomileusis. J Refract Surg 1999; 15:S227.
  44. Management and therapy of dry eye disease: report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:163.
  45. Perry HD, Solomon R, Donnenfeld ED, et al. Evaluation of topical cyclosporine for the treatment of dry eye disease. Arch Ophthalmol 2008; 126:1046.
  46. Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology 2000; 107:631.
  47. Baiza-Durán L, Medrano-Palafox J, Hernández-Quintela E, et al. A comparative clinical trial of the efficacy of two different aqueous solutions of cyclosporine for the treatment of moderate-to-severe dry eye syndrome. Br J Ophthalmol 2010; 94:1312.
  48. Sacchetti M, Mantelli F, Lambiase A, et al. Systematic review of randomised clinical trials on topical ciclosporin A for the treatment of dry eye disease. Br J Ophthalmol 2014; 98:1016.
  49. Wilson SE, Perry HD. Long-term resolution of chronic dry eye symptoms and signs after topical cyclosporine treatment. Ophthalmology 2007; 114:76.
  50. Vogel R, Crockett RS, Oden N, et al. Demonstration of efficacy in the treatment of dry eye disease with 0.18% sodium hyaluronate ophthalmic solution (vismed, rejena). Am J Ophthalmol 2010; 149:594.
  51. Avunduk AM, Avunduk MC, Varnell ED, Kaufman HE. The comparison of efficacies of topical corticosteroids and nonsteroidal anti-inflammatory drops on dry eye patients: a clinical and immunocytochemical study. Am J Ophthalmol 2003; 136:593.
  52. Pinto-Fraga J, López-Miguel A, González-García MJ, et al. Topical Fluorometholone Protects the Ocular Surface of Dry Eye Patients from Desiccating Stress: A Randomized Controlled Clinical Trial. Ophthalmology 2016; 123:141.
  53. Noble BA, Loh RS, MacLennan S, et al. Comparison of autologous serum eye drops with conventional therapy in a randomised controlled crossover trial for ocular surface disease. Br J Ophthalmol 2004; 88:647.
  54. Soni NG, Jeng BH. Blood-derived topical therapy for ocular surface diseases. Br J Ophthalmol 2016; 100:22.
  55. Pan Q, Angelina A, Zambrano A, et al. Autologous serum eye drops for dry eye. Cochrane Database Syst Rev 2013; :CD009327.
  56. Tsifetaki N, Kitsos G, Paschides CA, et al. Oral pilocarpine for the treatment of ocular symptoms in patients with Sjögren's syndrome: a randomised 12 week controlled study. Ann Rheum Dis 2003; 62:1204.
  57. Tauber J, Davitt WF, Bokosky JE, et al. Double-masked, placebo-controlled safety and efficacy trial of diquafosol tetrasodium (INS365) ophthalmic solution for the treatment of dry eye. Cornea 2004; 23:784.
  58. Miljanović B, Trivedi KA, Dana MR, et al. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr 2005; 82:887.
  59. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye 2008; 31:141.
  60. Wojtowicz JC, Butovich I, Uchiyama E, et al. Pilot, prospective, randomized, double-masked, placebo-controlled clinical trial of an omega-3 supplement for dry eye. Cornea 2011; 30:308.
  61. Kangari H, Eftekhari MH, Sardari S, et al. Short-term consumption of oral omega-3 and dry eye syndrome. Ophthalmology 2013; 120:2191.
  62. Rashid S, Jin Y, Ecoiffier T, et al. Topical omega-3 and omega-6 fatty acids for treatment of dry eye. Arch Ophthalmol 2008; 126:219.
  63. Drouault-Holowacz S, Bieuvelet S, Burckel A, et al. Antioxidants intake and dry eye syndrome: a crossover, placebo-controlled, randomized trial. Eur J Ophthalmol 2009; 19:337.
  64. Blades KJ, Patel S, Aidoo KE. Oral antioxidant therapy for marginal dry eye. Eur J Clin Nutr 2001; 55:589.
  65. Kim EC, Choi JS, Joo CK. A comparison of vitamin a and cyclosporine a 0.05% eye drops for treatment of dry eye syndrome. Am J Ophthalmol 2009; 147:206.
  66. Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev 2010; :CD006775.
  67. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease. Cornea 2007; 26:1195.
  68. Tseng KL, Liu HJ, Tso KY, et al. A clinical study of acupuncture and SSP (silver spike point) electro-therapy for dry eye syndrome. Am J Chin Med 2006; 34:197.
  69. Grönlund MA, Stenevi U, Lundeberg T. Acupuncture treatment in patients with keratoconjunctivitis sicca: a pilot study. Acta Ophthalmol Scand 2004; 82:283.
  70. Sheppard JD, Torkildsen GL, Lonsdale JD, et al. Lifitegrast ophthalmic solution 5.0% for treatment of dry eye disease: results of the OPUS-1 phase 3 study. Ophthalmology 2014; 121:475.
  71. Tauber J, Karpecki P, Latkany R, et al. Lifitegrast Ophthalmic Solution 5.0% versus Placebo for Treatment of Dry Eye Disease: Results of the Randomized Phase III OPUS-2 Study. Ophthalmology 2015; 122:2423.
  72. Sharma RA, Mather R. Five things to know about...dry eye disease. CMAJ 2014; 186:1090.