The Link Between Chronic Dry Eye and Comorbidities

Key Takeaways:

• Over 40 percent of CDE patients manage significant comorbidities, including allergies (49 percent), hypertension (45 percent), and cataracts (45 percent).
• CDE patients report struggling with anxiety (39 percent) or depression (38 percent) alongside their ocular symptoms.
• Only 25 percent of diagnosed patients feel their chronic dry eye is well-controlled under their current treatment plan.

Chronic dry eye (CDE) is increasingly recognized not as an isolated ocular nuisance, but as a complex, multifactorial manifestation of systemic health. While localized treatments like lubricants and anti-inflammatories remain staples of care, the underlying etiology often stretches far beyond the lacrimal unit.¹

Data from the 2023 and 2025 Chronic Dry Eye In America surveys provide a compelling look at the heavy burden of systemic comorbidities that accompany this condition.^2,3

The landscape of systemic comorbidity

The In America survey results highlight that CDE patients are rarely dealing with ocular issues in a vacuum. The average respondent age was 65 years, a demographic where systemic chronic conditions begin to cluster. Understanding these clusters is vital for clinicians to provide holistic care and accurately manage patient expectations.^2,3

According to the 2023 survey, the top reported comorbidities among CDE patients include:²

• Allergies (49 percent) – The most prevalent comorbidity, which often leads to a "double hit" on the ocular surface from both the allergic inflammatory response and the drying effects of systemic antihistamines.
• Hypertension (45 percent) and high cholesterol (39 percent) – These cardiovascular markers suggest a patient population with potential microvascular or metabolic concerns that may influence ocular surface health.
• Cataracts (45 percent) – Highlighting the overlap between CDE and other age-related ocular pathologies that can complicate surgical outcomes and patient satisfaction.

Autoimmune and inflammatory links

A significant subset of the CDE population exhibits comorbidities that point toward systemic inflammatory or autoimmune origins, specifically in conditions like rheumatoid arthritis (RA) and Hashimoto’s. In RA, systemic inflammation can lead to secondary Sjögren’s Syndrome, where the immune system targets the moisture-producing lacrimal and salivary glands.⁴

Notably, 27 percent of In America respondents reported hypothyroidism (e.g., Hashimoto’s thyroiditis), which is a known risk factor for ocular surface dysfunction.²

Additionally, 39 percent reported chronic pain and 23 percent reported osteoporosis, conditions that may overlap with systemic inflammatory syndromes or the long-term use of medications that alter mucosal moisture.^2,4

For clinicians, these figures underscore the necessity of a thorough systemic review. When a patient presents with CDE that is refractory to standard topicals, the prevalence of these comorbidities suggests that an underlying autoimmune or metabolic trigger may be present.⁴

The pharmacological burden

The link between systemic issues and CDE is often mediated by the "pharmaceutical footprint" of the patient. With 45 percent of survey respondents managing high blood pressure and 39 percent managing high cholesterol, the use of beta-blockers, diuretics, and other systemic medications is likely high.^2,5

These medications are known to decrease tear production or alter tear film composition. Clinicians must balance the necessity of these systemic treatments with the ocular side effects, often requiring a collaborative approach with the patient's primary care physician.⁵

The psychosocial connection: Anxiety and depression

Another striking piece of data from the In America survey is the high prevalence of mental health comorbidities. The 2023 survey found that:²

• 39 percent of patients reported anxiety
• 38 percent reported depression

Many common antidepressants (SSRIs) and anti-anxiety medications have anticholinergic effects, which physically reduce tear production, creating a "vicious cycle" where the treatment for the mind inadvertently worsens the eyes.⁵

In addition, the chronic nature of CDE symptoms creates a feedback loop of physical discomfort and psychological distress. Patient insights reveal the depth of this impact:^2,3

• 33 percent of patients report that CDE significantly negatively impacts their ability to drive at night.
• 36 percent report a significant impact on reading, and 31 percent on computer work.
• Only 23 percent of patients feel that their loved ones truly understand what it is like to live with CDE.

One respondent noted:²

"I know how bad my eyes look. They feel as bad as they look. I feel embarrassed."

Another highlighted the "constant" nature of the pain:²

"It's CONSTANT. I feel like there is never any relief from the discomfort."

Clinical implications and management

Despite the availability of various treatments, the 2025 survey indicates a significant gap in care. Only 25 percent of patients feel their condition is "well-controlled" with their current treatment plan. Furthermore, while more than half of patients seek information from their ophthalmologist, 44 percent feel they lack the support needed to manage the condition effectively.³

This suggests that for clinicians, managing CDE requires:

• Systemic screening – Identifying thyroid issues, comorbid conditions, allergies, and mental health struggles during the initial workup
• Validation – Acknowledging the significant quality of life impact to bridge the "understanding gap" reported by patients
• Proactive counseling – Discussing the latest treatment options, as 76 percent of patients express a high interest in learning about new therapies

The In America surveys make it clear that CDE patients are struggling with a high burden of comorbid allergies, cardiovascular issues, and mental health challenges. By shifting the clinical focus from the ocular surface to the whole patient, clinicians can move closer to achieving "well-controlled" status for patients who currently feel left behind.^2,3