History and exam

Key diagnostic factors

common

known underlying medical cause

Includes blepharitis, connective tissue disorders, vitamin A deficiency, hepatitis C, HIV, hematopoietic stem cell transplantation, laser in situ keratomileusis, contact lens use, diabetes mellitus, sarcoidosis, and Parkinson disease.

use of known causative medications

Includes preserved topical ophthalmic medications, postmenopausal hormone replacement therapy, oral contraceptives, antihistamines, beta-blockers, anticholinergics, diuretics, some psychotropic drugs, and retinoids.

corneal filaments

Small comma shaped strands, attached at one end to the cornea (corresponding to the lid aperture) may be evident on slit-lamp examination after staining with fluorescein or rose bengal.

Other diagnostic factors

common

ocular irritation/foreign body sensation

These nonspecific symptoms can be indicative of dry eye. Symptom severity does not always correlate with signs.[35]

ocular burning

This nonspecific symptom can be indicative of dry eye. Symptom severity does not always correlate with signs.[35]

transient blurred vision

Intermittent visual blurring may occur.

tearing

Reflex watering may be experienced with ocular surface irritation and also in patients with diabetes.

blepharitis/meibomianitis

Eyelid margin inflammation may be present on examination. [Figure caption and citation for the preceding image starts]: BlepharitisPrivate collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@1c85920b

punctate epithelial erosions

Fine punctate staining of the inferior cornea (corresponding to the lid aperture) may be evident on slit-lamp examination after staining with fluorescein or rose bengal.

conjunctival punctate erosions

Fine punctate staining of the conjunctiva may be evident on slit-lamp examination after staining with fluorescein, rose bengal, or lissamine green stain. [Figure caption and citation for the preceding image starts]: Dry eye (stained with rose bengal)Private collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@4ae6f366

conjunctival injection

Injected conjunctiva may be a presenting sign.

uncommon

lagophthalmos

Inability to fully close lid apertures leads to increased tear film evaporation.

proptosis

Eyeball protrusion or displacement can lead to difficulty with lid closing. This leads to increased tear film evaporation.

presence of mites

Careful examination of the base of the eyelashes may reveal Demodex mites, which can cause ocular irritation and refractory dry eye.

Risk factors

strong

female sex

It is well documented that the condition is more prevalent in females than males.[3][4][5]

older age

Older age is a well-established risk factor that may be due to reduced lacrimal gland function in older adults.[3][6]

blepharitis/meibomianitis

Eyelid margin inflammation may pre-empt dry eye.[3][Figure caption and citation for the preceding image starts]: BlepharitisPrivate collection of Dr Jonathan Smith and Dr Philip Severn; used with permission [Citation ends].com.bmj.content.model.Caption@b702854

connective tissue disorders

Many connective tissue disorders, including Sjögren syndrome, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis (scleroderma), and mixed connective tissue disorder), are associated with lacrimal acinar damage and dry eye.[3]

vitamin A deficiency

Dry eye, with or without aqueous deficiency, can occur with vitamin A deficiency, which affects tear film instability.[3]

hematopoietic stem cell transplantation

Dry eye has been reported in allograft recipients and is a common complication of graft versus host disease.[21]

lens and eyelid surgery

Dry eye is a common complication of ocular surgery (e.g., prior keratoplasty, cataract surgery, and keratorefractive surgery) and eyelid surgery (e.g., punctal cautery, prior ptosis repair, blepharoplasty, entropion/ectropion repair).[2]

contact lens use

Contact lens use causes tear film hyperosmolarity; however, scleral lenses may be beneficial to selected patients as they can help the healing of persistent corneal epithelial defects secondary to dry eye.[13]

diabetes mellitus

Increased prevalence of dry eye has been reported in diabetic patients.[3]

systemic medications

Many systemic medications (including antiandrogenic treatments, oral contraceptives, antihistamines, beta-blockers, anticholinergics, diuretics, some psychotropic drugs, and retinoids) are known to cause dry eye.[3]

Postmenopausal hormone replacement therapy has been linked with an increased risk of dry eye.[16]

The mechanisms of action vary depending on specific pharmacologic properties.

preserved topical ophthalmic medications

Preservatives such as benzalkonium chloride can induce symptoms and signs of dry eye.[3][12]

sarcoidosis

Lacrimal gland involvement in sarcoidosis causes dry eye.[3][22]

Parkinson disease

Patients may develop dry eye due to autonomic dysfunction and reduced blink rates.[11]

weak

hepatitis C

Dry eye has been observed in hepatitis C infection.[3][19]

HIV

T-cell involvement can lead to dry eye occurring with HIV infection.[3][20]

environmental factors

Environmental factors such as wind, low humidity, and increased air temperature can worsen dry eye by increasing tear film evaporation.[3]

occupational factors

Occupations requiring sustained visual attention, such as microscope work and computer screen usage, can reduce blink rates and increase tear evaporation.[3]

headache

One meta-analysis of 11 studies demonstrated headache, particularly migraine, as an independent risk factor for dry eye disease.[23]

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