Dry Eye Severity Correlated With Presence of Systemic Disease

Researchers demonstrate more severe dry eye disease in patients with Sjogren syndrome, facial rosacea, and rheumatoid arthritis.

While several systemic diseases are associated with dry eye disease (DED), researchers now say evidence points to certain systemic conditions being associated with patients having more severe dry eye signs than patients without the condition. The study, published in Ophthalmology, reviewed cases involving Sjogren syndrome, facial rosacea, thyroid dysfunction, osteoarthritis, diabetes, irritable bowel syndrome, hypercholesterolemia, hypertension, hypertriglyceridemia and rheumatoid arthritis.

The profile of significant DED signs varied by systemic condition, reflecting different DED etiologies. Patients with a history of smoking also demonstrated greater DED severity. Researchers conducted the secondary analysis of data from the Dry Eye Assessment and Management (DREAM) study — a large-scale randomized clinical trial of patients with moderate-to-severe DED — to investigate a link between systemic conditions that are known risk factors for DED and DED severity.

The study included 535 adult patients from 27 centers in the United States (81% women, mean age was 58+13.2 years). At baseline, participants reported their medical histories, followed by ocular surface exams, and symptom evaluations. Follow-up visits were scheduled for 6 months and 12 months later. The 6 DED signs evaluated included tear break-up time, anesthetized Schirmir testing, cornea fluorescein, conjunctival lissamine green staining, tear osmolarity, and meibomian gland dysfunction.

The main outcome measures were DED symptoms using the Ocular Surface Disease Index (OSDI), 6 specific DED signs, and a composite signs severity score with range 0-1 calculated from the signs. The researchers found that more severe signs of DED had a significant association with Sjogren syndrome (P <.001), facial rosacea (P =.002), and rheumatoid arthritis (P =.002). Other conditions associated with worse DED signs included a history of daily smoking (P =.047) and peripheral artery disease (P <.001).  Thyroid dysfunction, osteoarthritis, diabetes, irritable bowel syndrome, hypercholesterolemia, hypertension, and hypertriglyceridemia were not associated with more severe DED. 

The researchers note that older age was not associated with higher OSDI scores, even though it has been associated with more severe signs of DED, perhaps due to reduced corneal sensitivity.

A notable study limitation, according to researchers, includes a possible underestimation of certain systemic conditions with DED severity due to potential bias from coexisting diseases. Also, since the study population was limited to patients with moderate-to-severe DED, this could have also led to bias.

“The lack of significant associations for some of the systemic conditions, such as diabetes and thyroid dysfunction, should be interpreted in this context,” the study explains. “For example, it is possible that these systemic conditions are associated with mild but not moderate-to-severe DED.”


Yu K, Bunya V, Maguire M, Asbell P, Ying G, DREAM Study Research Group. Systemic conditions associated with severity of dry eye signs and symptoms in the dry eye assessment and management (DREAM) study. Ophthalmol. Published online March 27, 2021. doi:10.1016/ j.ophtha.2021.03.030.