Many eye surgeons are noticing more patients coming in with more Dry Eye disease due to increased electronic screen time, and sometimes also of course, due to underlying autoimmune disease. When patients have a lot of screen time and their oil glands have dried up, it can lead to chronic Dry Eye symptoms and excruciating 10 out of 10 pain that can lead to suicidal ideation.
We have some objective data to show patients the cause of this, but sometimes the objective data is missing and patients still want to be able to work from home.
The data shows that when patients work from home, their electronic screen time can go up. How should we deal with this when a patient is asking for disability?
This is one of the hardest conversations in a busy cornea and ocular surface clinic, and it is coming up more and more often. The patient is suffering. The suffering is real even when the slit lamp exam looks better than the symptoms suggest. And the request feels reasonable on its face. Home is quiet, home is private, home has no fluorescent lights and no conference room air vent blowing directly across the ocular surface. But the medical literature does not actually support a blanket work from home accommodation as a treatment for Dry Eye disease, and I think we owe our patients honesty about that.
What the Evidence Actually Shows
Let me start with what is not in question. Dry Eye disease genuinely impairs work. In the DREAM study, worse OSDI symptom scores were associated with roughly 4.3 percent greater overall work impairment for every 10 unit increase in OSDI. A systematic review including more than 50,000 participants found presenteeism around 25 percent, absenteeism around 19 percent, and activity impairment around 30 percent in Dry Eye patients without Sjögren syndrome. The 2018 New England Journal of Medicine review by Clayton put the societal cost in the United States at roughly 55 billion dollars a year, driven largely by the fact that Dry Eye makes computer use and reading harder, narrows the range of tolerable environments, and cuts into productive work time.
So the impairment is documented, quantifiable, and expensive. That is not the issue.
The issue is that no published guideline and no published study recommends remote work as a treatment or accommodation for Dry Eye disease. And the pandemic gave us a very large natural experiment on exactly this question. During lockdowns, global Dry Eye prevalence rose to roughly 61 percent, driven largely by increased video display terminal use at home. A Thai study found that mean daily screen time rose from 10.5 hours to 13.1 hours during lockdown, and that the increase in screen time was independently associated with worsening Dry Eye symptoms, with an odds ratio of 5.68.
Read that again, because it is the crux of the problem. The intervention the patient is asking for is associated with more of the exposure that is driving the disease. When people work from home, the commute disappears, the meetings become screens, the lunch break becomes a screen, and the natural interruptions that force a person to look away from a monitor and blink completely disappear. Home is not a low screen environment. Home is frequently the highest screen environment in a person's life.
If I write a letter saying that remote work is medically necessary for Dry Eye disease, I am writing something the literature does not support, and I may be recommending an arrangement that makes my patient worse.
What the Guidelines Do Support
The American Academy of Ophthalmology Preferred Practice Pattern and TFOS DEWS III both point to specific environmental and ergonomic modifications, and here is the important part, every one of these can be implemented at any worksite. They are not location dependent.
Humidity control is the one environmental modification with actual evidence behind it in occupational settings. Indoor air humidification improves Dry Eye symptoms. Target humidity is 40 to 60 percent, and a desktop humidifier accomplishes this at a cubicle just as well as it does at a kitchen table.
Ergonomic adjustment matters more than most people realize. Lowering the monitor below eye level narrows the lid aperture, which reduces the exposed ocular surface area and slows tear evaporation. This is basic physics applied to the tear film, and it costs nothing but a few minutes with an adjustable chair and a monitor arm.
Scheduled breaks from screen use are recommended, and the 20/20/20 rule is the version everyone knows, though it has never been formally studied as such. Blink training is better supported. Blink animation programs improve both signs and symptoms of screen associated Dry Eye.
Air draft avoidance is straightforward once you look for it. Side shields on spectacles, redirecting or blocking an air vent, moisture chamber eyewear. I have had patients whose entire symptom burden was traced to sitting directly under an HVAC diffuser.
And omega 3 supplementation has some evidence for symptom improvement, though the trial data is mixed enough that I present it as an option rather than a mandate.
Notice what is on this list and what is not. Every item describes an environment or a behavior. Not one of them describes an address.
How I Handle the Accommodation Request
Here is the framework I have landed on, and it has made these visits considerably less fraught.
Under the Americans with Disabilities Act, the physician's job is to document the medical condition and the functional limitations it produces, and to identify medically supported accommodations. The physician's job is not to dictate the employment arrangement. The employer then engages in what the law calls the interactive process to figure out how to deliver those accommodations. This division of labor is not a technicality that lets us dodge a hard conversation. It is genuinely the correct allocation of expertise. I know the ocular surface. I do not know whether this patient's specific job requires physical presence for reasons I have never heard of.
So the letter I write describes the diagnosis, the functional limitations, and the modifications. It does not name a location.
The functional limitations section states that the condition affects sustained use of video display terminals without breaks, tolerance of low humidity or forced air or direct airflow, and prolonged reading or visually demanding tasks without interruption.
The accommodations section is organized in four parts. Environmental controls, meaning a desktop humidifier targeting 40 to 60 percent humidity, workstation repositioning away from vents and fans and drafts, and avoidance of a workstation in direct sun. Ergonomic modifications, meaning a monitor positioned below eye level, an antiglare filter, and an adjustable chair. Work schedule modifications, meaning a scheduled five minute break every 20 to 30 minutes of sustained screen use for blinking exercises and drop instillation, plus flexibility for brief unscheduled breaks for symptom management. And permitted use of treatments at the workstation, meaning preservative free artificial tears as needed, moisture chamber eyewear or side shields if needed, and access to warm compress materials for lid therapy.
The letter closes by stating that the patient is capable of performing the essential functions of the position with these accommodations in place.
Then something interesting happens. Sometimes the employer reads that list, looks at the open plan office with the overhead diffusers and the mandatory meeting cadence, and concludes that the most feasible way to deliver a humidified, draft free workstation with a flexible break schedule is a hybrid or remote arrangement. That is a legitimate outcome. But it arrived as the employer's operational decision, not as my medical prescription. That distinction protects the patient, protects the employer, and protects me.
The Patients Where This Gets Harder
I want to be careful not to make this sound tidier than it is.
For patients with severe or refractory disease, and here I am thinking of Sjögren syndrome, neurotrophic keratopathy, severe aqueous deficiency, the functional limitations are genuinely more extensive and the letter should reflect that. Sjögren patients demonstrate meaningfully lower employment rates and higher work disability in the published data. The accommodation list for those patients is longer and the limitations are more categorical.
And then there is the patient I opened with. The one with 10 out of 10 pain, atrophied meibomian glands on meibography, and a slit lamp exam that does not remotely explain the suffering. Neuropathic ocular pain is real, it is underdiagnosed, and it is the population where the gap between objective findings and subjective misery is widest. When a patient in that category tells me the pain has made them think about ending their life, that is not a disability paperwork conversation anymore. That is an urgent clinical conversation, and it needs a real referral and a real safety plan, not a form letter. I say this plainly because I think the specialty has been slow to acknowledge how severe this pain gets.
What I Would Ask of Colleagues
Document objectively and document early. OSDI scores at every visit. Corneal and conjunctival staining grades. Tear breakup time. Meibography images. Osmolarity if you have it. When the accommodation request eventually comes, and it will, the strength of the letter depends entirely on whether you built a longitudinal record or are trying to reconstruct one from a single visit.
Resist the temptation to write the note the patient is asking for just because the visit is running long and the patient is upset. A letter prescribing remote work for Dry Eye is a letter the literature will not back you on, and it may hand the patient a 13 hour screen day.
And say the honest thing out loud in the room. Something like this has worked for me. I believe your pain. I am going to document exactly how this condition limits you. And I am going to fight for the things that will actually help your eyes, which are humidity, airflow control, break structure, and blink retraining. Those things follow you wherever you work. What I cannot honestly tell your employer is that being at home will make your eyes better, because the evidence suggests it often does the opposite.
Most patients accept that. What they wanted, underneath the request, was to be believed.
References
Neti N, Prabhasawat P, Chirapapaisan C, Ngowyutagon P. Provocation of Dry Eye Disease Symptoms During COVID 19 Lockdown. Scientific Reports. 2021;11(1):24434.
Ji H, Yang Y, Lu Y, et al. Prevalence of Dry Eye During the COVID 19 Pandemic: A Systematic Review and Meta Analysis. PLoS One. 2023;18(12):e0288523.
American Academy of Ophthalmology. Dry Eye Syndrome Preferred Practice Pattern. 2024.
Kamøy B, Magno M, Nøland ST, et al. Video Display Terminal Use and Dry Eye: Preventive Measures and Future Perspectives. Acta Ophthalmologica. 2022;100(7):723 to 739.
Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III Management and Therapy Report. American Journal of Ophthalmology. 2025.
Greco G, Pistilli M, Asbell PA, Maguire MG. Association of Severity of Dry Eye Disease With Work Productivity and Activity Impairment in the Dry Eye Assessment and Management Study. Ophthalmology. 2021;128(6):850 to 856.
Sivakumar GK, Patel J, Malvankar Mehta MS, Mather R. Work Productivity Among Sjögren's Syndrome and Non Sjögren's Dry Eye Patients: A Systematic Review and Meta Analysis. Eye. 2021;35(12):3243 to 3257.
Clayton JA. Dry Eye. New England Journal of Medicine. 2018;378(23):2212 to 2223.
McCann P, Kruoch Z, Lopez S, et al. Interventions for Dry Eye: An Overview of Systematic Reviews. JAMA Ophthalmology. 2024;142(1):58 to 74.
Blanck PD, Folberg R. The Americans With Disabilities Act. Emerging Issues for Ophthalmologists. Ophthalmology. 1994;101(9):1635 to 1640.
This post is for educational purposes and does not constitute medical or legal advice. Accommodation decisions should be individualized and made in consultation with the treating physician and, where appropriate, legal counsel.
Workplace Accommodation Letter for Dry Eye Disease
[Date]
To Whom It May Concern:
Re: Workplace Accommodations for [Patient Name]
Date of Birth: [DOB]
I am writing to confirm that the above-named patient is under my care for a diagnosis of dry eye disease (ICD-10: H04.12), a chronic multifactorial condition of the ocular surface that causes symptoms including ocular discomfort, visual fluctuation, and difficulty with sustained visual tasks.
FUNCTIONAL LIMITATIONS:
This condition affects the patient's ability to perform the following work-related activities:
- Sustained use of computer/video display terminals without breaks
- Working in environments with low humidity, forced-air heating/cooling, or direct airflow
- Prolonged reading or visually demanding tasks without interruption
RECOMMENDED WORKPLACE ACCOMMODATIONS:
Based on the patient's clinical condition, the following environmental and ergonomic modifications are medically recommended to enable the patient to perform essential job functions:
1. Environmental Controls
- Use of a desktop humidifier at the workstation (target humidity 40–60%)
- Repositioning of the workstation away from direct air vents, fans, or drafts
- Avoidance of workstations near windows with direct sunlight exposure
2. Ergonomic Modifications
- Computer monitor positioned below eye level to reduce lid aperture and tear evaporation
- Provision of an anti-glare screen filter for the computer monitor
- Adjustable chair to allow proper screen positioning
3. Work Schedule Modifications
- Scheduled 5-minute breaks every 20–30 minutes of sustained screen use to perform blinking exercises and apply prescribed eye drops
- Flexibility to take brief unscheduled breaks as needed for symptom management (eye drop application, warm compresses)
4. Permitted Use of Medical Devices/Treatments at Workstation
- Use of preservative-free artificial tears as needed throughout the workday
- Use of moisture chamber eyewear/protective side shields if needed
- Access to warm compress materials for periodic lid therapy if helpful to patient
The patient is capable of performing the essential functions of their position with the above accommodations in place. These recommendations are based on current clinical evidence and guidelines for the management of dry eye disease.
Please contact my office if further information is needed.
Sincerely,
[Physician Name, Credentials]
[Practice Name]
[Contact Information]
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