Is It Getting Worse?

An article we found late last year on Medscape Not A Dry Eye Blogpuzzled us. In it the reporter, Diana Swift, did not conclude that Dry Eye symptoms get worse over time. Instead she concluded that,

Despite the general perception, dry eye disease does not necessarily worsen over time. Most patients report no progression, and some even report improvement, according to a retrospective survey-based study of healthcare professionals having the condition for an average of more than 10 years.

Sounds good, right?

But not if you have the disease and not necessarily if you were one of the authors of the study who concluded that:

A proportion of patients with DED experience worsening over time, tending to report with more severe symptoms earlier in the disease.

So it seems there’s a disconnect. The reporter is looking at the data and saying things don’t get worse, but the authors of the study are saying something else.

And when we looked further into the study, we found this

The most common response of study participants was to report no change since the time of their initial DED diagnosis (Fig 1Fig 1): 32.0% for ocular surface symptoms, 52.3% for vision-related symptoms, and 71.1% for social impact. Some amount of improvement since diagnosis was reported by 44.0% for ocular surface symptoms, 19.0% for vision-related symptoms, and 19.2% for social impact. Some amount of worsening was reported by 24.1% for ocular surface symptoms, 28.7% for vision-related symptoms, and 9.7% for social impact.

So although some people reported getting better, others reported getting worse. Could it be that the reporter was simply ignoring the poor people in the study who were getting worse?

In fact, a different interpretation of the same results suggests that, since the time of diagnosis, very few individuals in the study improved at all. Less than 50% improved in Ocular Surface Symptoms (A) and less than 20-25% improved in vision-related symptoms (B) and social impact (C).

And some people clearly got worse:

For ocular surface symptoms, 27.7% of women versus 20.4% of men reported at least some worsening, whereas 30.9% of women and 26.5% of men reported at least some worsening of vision-related symptoms. More men (11.3%) than women (8.0%) reported worsening of social impact of their DED.

Plus this:

Among participants who reported severe OSDI scores … 31.5% experienced worsening of ocular surface symptoms, versus 16.1% of participants with mild to moderate OSDI scores.

So, yes, some people do get worse. But the reporter’s conclusion seems to largely dismiss the symptoms of these individuals, especially those who had mild or moderate symptoms that got worse.

The majority of men and women with DED recalled little or no change in ocular surface symptoms, vision-related symptoms, or the social impact of DED since diagnosis, and a similar number reported an improvement as reported worsening. These results, supported by review of clinical records, call into question the suggested tendency for DED to progress over time.

Why would the reporter conclude that? It clearly gets worse for some people…and most people don’t get better.

Dry Eye Symptoms Get Worse

So here’s a study about Dry Eye with statements that we largely agree with, but that a reporter seems to misinterpret and understate, causing confusion all around.

Because we truly think the authors of the study are on to something when they say that the results

also point to possible inadequacies of current therapies.

It’s more than possible inadequacies. Most of us can attest to that. And it’s especially true if the therapies are the typical ones (lubricating drops, warm compresses, lid wipes and Restasis), stemming from superficial diagnoses – aqueous tear deficiency, evaporative dry eye or blepharitis – without further examining for specific and underlying cause – like obstructive meibomian gland dysfunction (O-MGD).

The authors of the study go on to say, and we agree with them wholeheartedly:

Given the significance of DED as a public health concern, we hope that increasing knowledge of the disease will result in improvements of its clinical management. We would encourage clinicians to not only investigate potential causes of corneal epitheliopathy but also inquire routinely in a more standardized fashion about symptoms of DED. Simple short questionnaires, such as the Symptom Assessment in Dry Eye questionnaire, have been developed and may be useful for this purpose.

And we truly applaud this:

One of the most consistent correlates of worsening was a record of past severe symptoms. This finding is in line with the idea that patients who present with more severe symptoms early in the course of their disease are the ones who are most likely to experience a worsening, usually despite therapy. Patients with more severe symptoms may be more likely to see their doctor more often or to seek specialist care, and this could lead to a skewed perception of disease progression among clinicians.

And perhaps most importantly this:

The present data also suggest the continued need for more effective treatments for DED. … and these new data show that approximately 30% of such patients experience some level of long-term worsening, regardless of therapy. People who reported spending more than $20 per month on dry eye treatments were more likely to experience worsening, likely because people with worsening symptoms seek relief.

Seeking relief. We all know what that’s like. Because yes, Dry Eye symptoms get worse.

Send your comments to


Dry Eye Disease does not worsen with time in most patients
D. Swift
Medscape Medical News
December 30, 2015

Severity of symptoms, corneal ulcers, and associated factors among men and women with dry eye disease
L.P. Leinert, L. Tarko, M. Uchino, W.G. Christen, D.A. Schaumberg
Published Online: November 21, 2015. DOI:
View the full report

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