Dry eye disease (DED) can be emotionally trying for doctor and patient. While many patients’ mild to moderate complaints can be managed with medications and in-office treatments, others flounder in misery. Often, their symptoms far exceed their signs, raising a “chicken or egg” type of question: Is it the dry eye devastating their lives or are changes in their lives driving the dry eye symptomatology?

Pain and Perception

It is often noted that signs and symptoms of DED do not match. Consider that dry eye syndrome may be the manifestation of a larger disease process rooted—at least in part—within the mind.

Patients’ symptoms are frequently driven by ocular surface damage and chronic inflammation. However, the role of pain perception, psychosomatic features triggered by the subconscious or unconscious and overall decline in a patient’s sense of well-being can’t be discounted. DED is classically more associated with women, aging, hormonal changes, medications and autoimmune disease. Depression and anxiety also correlate with DED.1,2 Stress mediators, such as cortisol and dehydroepiandrosterone (DHEA), have been identified in the tear film.3 

This patient appears essentially normal with ample tear prism, but remains symptomatic.

Pain perception stems from a complex combination of genetic and environmental factors that can be further influenced by gender, ethnicity and personality.4 Chronic pain can also be triggered by personality traits.3 In a study conducted at Duke University Medical Center, more than 2,000 students answered the Minnesota Multiphasic Personality Inventory (MMPI).4 Thirty years later, participants completed a self-reported questionnaire about chronic pain. Comparison of the MMPI and follow-up survey found correlations between MMPI in college and development of chronic pain.4

Psychosomatic conditions are bodily symptoms caused by mental or emotional disturbance. Unfortunately, some may consider psychosomatosis simply “a figment of the patient’s imagination” rather than a physiological embodiment of a psychological stressor, but, in fact, psychological stress can provoke neurological suppression of lacrimal gland function.5,6

Further research explains that changes to the limbic system—which influences the autonomic nervous system and is responsible for motivation, emotional response, memory and social cognition—due to stressors such as anxiety, fatigue and sleep disruption can decrease basal tear secretion.7,8

Treat the Patient, Not Just Symptoms

Some patients present with symptoms that prove difficult to treat. A modest decrease in tear break-up time results in profound symptoms and impact to quality of life (QoL). A study of 229 subjects found tear break-up time and Schirmer’s scores were lower in patients diagnosed with DED than those who had dry eye symptoms alone, but no signs. The same patients had significantly lower composite scores on the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) with both subscale scores of ocular pain and mental health measuring lower.9

Failure of signs and symptoms to correlate can lead to a disconnect between the doctor and patient. If we appear dismissive of a patient’s complaints, the patient will leave disheartened. Consider exploring your patients’ symptoms further by using surveys designed to drill deeper into the psychological contributors to their condition. Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) are commonly used surveys to give objective value to subjective complaints. While valuable clinically, neither offers insight into the patient’s emotional status. Surveys such as Impact of Dry Eye on Everyday Life (IDEEL), National Eye Institute’s Visual Function Questionnaire (NEI VFQ-25), and The Short Form-36 (SF-36) provide information about the patient’s quality of life.

• IDEEL. Comprised of 57 questions consisting of three modules: (1) dry eye symptom bother, (2) impact on daily life (routine activities, emotional status and work) and (3) treatment satisfaction (effectiveness and treatment-related bother/inconvenience).10 The IDEEL questionnaire is a valid and comprehensive survey specifically directed at dry eye disease.
• NEI VFQ-25. A general visual function survey consisting of five nonvisual categories (general health, mental health, dependency, social function, role limitations) and seven visual categories: general vision, distance vision, peripheral vision, driving, near vision, color vision and ocular pain. The survey is particularly valuable for evaluation of vision-related QoL.10 
• SF-36. A general health-related QoL survey that has been applied to dry eye disease. The questionnaire is comprised of 36 multipurpose questions investigating physical functioning, role limitation due to physical disability, bodily pain, general health, vitality, social functioning, emotional limitation due to emotional disability, and mental health. These items are then divided into a physical component summary score and a mental component survey score.10 The SF-36 takes approximately 10 minutes to complete.


A more expansive case history can shed light on treatment-resistant dry eye patients. While a review of systems covers psychiatric conditions, asking specific questions about history of depression and anxiety can be beneficial; DED frequently accompanies both, and increases with longer duration. Precipitating events triggering psychiatric conditions may also precede development of dry eye–related symptoms or increase the level of complaint.11 This is especially true for older patients with longer psychiatric history and use of selective serotonin reuptake inhibitors (SSRIs).11 Patients taking SSRIs had decreased Schirmer’s testing relative to those taking serotonin-norepinephrine reuptake inhibitors regardless of duration of usage.12 

Commonly Prescribed SSRIs in the United States

1. Cymbalta, Eli Lilly

2. Pristiq, Wyeth

3. Viibryd, Merck 

4. Celexa, Allergan

5. Zoloft, Pzifer

6. Prozac, Eli Lilly

7. Trazodone

8. Lexapro, Forest Laboratories

9. Paxil, GlaxoSmithKline

10. Effexor, Wyeth

The association of dry eye disease with autoimmune conditions is widely accepted. The etiology of autoimmune disease, like dry eye, is multifactorial and not well defined. Potential origins are rooted in genetics, environmental factors, hormone changes and immunological components. However, 50% are considered to have “unknown trigger factors.”13 Retrospective studies have identified up to 80% of patients encountering uncommon emotional stress before the development of autoimmune disease.13 Candid conversations with patients about dramatic alterations in their lives can help pinpoint the onset of symptoms and foster communication between doctor and patient. 

Sleep patterns should also be discussed with patients. Somnolence may be driven by a variety of mental illnesses, including depression. Circadian tear production maintains a heightened tear level in the morning and a subsequent decrease throughout the day. Lowest basal tear secretion is reported while sleeping. Up to 97% of patients with depression report sleep difficulties and 59% note that their QoL was adversely affected. While hypersomnia is less common, some patients can experience both hypersomnia and insomnia in the same depressive event.14

Giving extra attention to a patient’s emotional history and the onset of dry eye symptoms can provide necessary insight into the disease process. Treatment-resistant patients often transition from practitioner to practitioner in search of a compassionate and patient doctor who will partner with them in their difficult journey. Building that bond often creates a patient for life. 

1. Kim K, Han S, Han E, et al. Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci. 2011;52(11):7954-8.

2. Li M, Gong L, Sun X, Chapin W. Anxiety and depression in patients with dry eye syndrome. Curr Eye Res. 2011;36(1):1-7.

3. Banbury L. Stress biomarkers in the tear film [dissertation]. Lismore, NSW, AU: Southern Cross University; 2009.

4. Jarrett C. Ouch! The different ways people experience pain. The Psychologist. 2011;24:416-20.

5. Applegate K, Keefe F, Siegler I, et al. Does personality at college entry predict number of reported pain conditions at mid-life? A longitudinal study. J Pain. 2005 Feb;6(2):92-7.

6. Nepp J. Psychosomatic aspects of dry eye syndrome. Ophthalmologe. 2016;113(2):111-9.

7. Rajmohan V, Mohandas E. The limbic system. Indian J Psychiatry. 2007; 49(2):132–9.

8. Murube, J, Németh J, Höh H, et al. The triple classification of dry eye for practical clinical use. Eur J Ophthalmol. 2005 Nov-Dec;15(6):660-7.

9. Le Q, Zhou X, Ge L, et al. Impact of dry eye syndrome on vision-related quality of life in a non-clinic-based general population. BMC Ophthalmology. 2012; 12(1):22.

10. Uchino M, Schaumberg D. Dry eye disease: Impact on quality of life and vision. Curr Ophthalmology Reports. 2013; 1(2):51-7.

11. Wen, W, Wu Y, Chen Y, et al. Dry eye disease in patients with depressive and anxiety disorders in Shanghai. Cornea. 2012;31(6):686-92.

12. Koçer E, Koçer A, Özsütçü M, et al. Dry eye related to commonly used new antidepressants. J Clin Psychopharmacol. 2015;35(4):411-3. 

13. Stojanovich L, Marisavljevich D. Stress as a trigger of autoimmune disease. Autoimmun Rev. 2008;7(3):209-13.

14. Nutt D, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008; 10(3):329–36.