Patients who are diagnosed with dry eye disease (DED) and use over-the-counter lubricating eye drops presumably should experience similar health-related quality-of-life (HR-QoL) to undiagnosed individuals who have similar symptoms and apply artificial tears. However, a 78,165-participant study from The Netherlands indicates that being undiagnosed is associated with a greater risk for low mental quality-of-life as symptoms worsen, according to the analysis published in Ocular Surface.

Even with a diagnosis, the 36-Item Short Form Survey (SF-36) revealed this condition is a problem that lowers physical and mental HR-QoL comparably with other chronic and systemic diseases. “Allergic conjunctivitis, glaucoma, macular degeneration and retinal detachment, DED showed the highest risk of low HR-QoL,” the study explains.

This large-scale analysis was based on the multi-disciplinary lifelines cohort; recruited through general practitioners and self-enrollment. The sample included those from 19 to 94 years of age; 59.2% women. Surveys included the Women’s Health Study (WHS) — a customary tool to assess dry eye — completed from 2014 to 2018, and SF-36 questionnaires completed from 2006 to 2014. Low physical or mental HR-QoL was defined as an aggregate score of 8 domains falling below median in the physical component summary (PCS), or below median in the mental component summary (MCS).

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Of the total, 8.9% had dry eye, and 1.8% displayed “highly symptomatic dry eye.” Individuals with DED were more likely to have a low HR-QoL score in all 8 domains, and both summary scores. Low physical HR-QoL was revealed in 62% of those with dry eye, compared with 49% of normal individuals (P <.0005), and low mental HR-QoL was discovered in 58% of participants with DED, and 49% of those without (P <.0005). Individuals who were highly symptomatic were 71% more prone to low PCS and 68% more susceptible for low MCS scores.

Factors of sex and age did not have remarkably significant effects on HR-QoL (P >.05), but for those with highly symptomatic dry eye, being older than 60 years of age reduced connection strength of dry eye to low PCS (P =.16). For men with highly symptomatic dry eye, there was a higher risk of low PCS than females with similar symptom severity (P =.01), but less strong risk for low MCS (P =.09).

At baseline and follow-up visits, participants were asked whether they were experiencing any of a comprehensive list of disorders. Of these, investigators eventually adjusted data for 52 comorbidities, along with correction for sex, age, education completed, and BMI. Participants with highly symptomatic dry eye had a greater chance for low PCS and MCS than any eye condition studied, including glaucoma needing surgery. 

Prior research has not fully explored DED symptom severity or taken comorbidities into consideration. Also, it has been previously unknown whether diagnosis vs non-diagnosis of DED impacts HR-QoL. Since the current analysis is cross-sectional, it cannot determine causal relationships, which is a limitation of the study, and there were no objective tests for dry eye level. Strengths included a large sample, and correction for many comorbidities.

According to the investigation, prompt diagnosis is crucial — and “findings suggest that psychological support should be given a larger focus in dry eye consultations.”


Morthen MK, Magno MS, Utheim TP, et al. The physical and mental burden of dry eye disease: A large population-based study investigating the relationship with health-related quality of life and its determinants. Ocular Surface. Published online May 24, 2021. doi:10.1016/j.jtos.2021.05.006