Dry Eye Disease
The Hidden Epidemic: Why Dry Eye Is Underreported and Which Medications Make It Worse
I believe dry eye disease is dramatically underreported, both here in the United States and around the world, and I expect the true numbers to keep climbing for years to come.
The reason is sitting in almost everyone's hand. We are addicted to our screens, and our children may be the most vulnerable of all. Every scroll delivers a small hit of dopamine, and while we chase that reward we forget to blink. Over time this rewires the brain to blink less often. Each full blink is what milks the essential oil out of the meibomian glands that line the eyelid margin. When the blink slows, that oil stops flowing, the tear film breaks apart too quickly, and the surface of the eye begins to suffer. This is why I expect the rates to keep rising rather than level off.
Many patients travel from other countries to see me for dry eye disease. This is especially true before and after cataract or glaucoma surgery. Patients who already know someone struggling with chronic dry eye want to understand their own risk before they commit to an operation, and they are right to ask.
What has struck me most over the past few years is how many young patients, many of them in their twenties, arrive with dry eye after starting medications that are rarely named as causes in the published literature. Isotretinoin, sold as Accutane, is the well known offender. Far less discussed are finasteride and spironolactone. It is difficult to separate how much of the increase comes from the medication itself and how much comes from heavy screen use, which for this purpose I define as more than four hours a day. What we do know is that there is real evidence these drugs can worsen dry eye on their own, even before you add the screen time on top.
My recommendation is simple. If you have any symptoms of dry eye disease, see a dry eye specialist as soon as you can. The earlier we intervene, the more meibomian gland function we can protect.
Below is a plain summary of what we currently understand about four medications that can cause or worsen dry eye, followed by a broader table of the many drug groups known to make it worse.
Four medications worth knowing about
| Drug type | A 5 alpha reductase inhibitor |
| Common uses | Enlarged prostate (Proscar, 5 mg) and male pattern hair loss (Propecia, 1 mg) |
| How it affects the eye | It blocks the conversion of testosterone to dihydrotestosterone, lowering androgen signaling. Androgens are essential for healthy meibomian and lacrimal gland function, so reduced androgen activity can drive meibomian gland dysfunction and lower both the oil and the water in the tear film. |
| Strength of evidence | Emerging. Supported by case reports and by our understanding of how androgens govern the tear glands. Not yet named in most standard dry eye references. |
| Typical presentation | Evaporative dry eye from meibomian gland dysfunction, with burning, fluctuating vision, and symptoms that worsen at the screen. |
| Clinical note | Symptoms can linger in some patients even after the drug is stopped, part of what patients online describe as post finasteride syndrome. |
| Drug type | An aldosterone antagonist and androgen receptor blocker, also a potassium sparing diuretic |
| Common uses | Hormonal acne, especially in young women, along with hirsutism, polycystic ovary syndrome, high blood pressure, and heart failure |
| How it affects the eye | It works through two routes. It blocks androgen receptors, removing the androgen support that the meibomian and lacrimal glands rely on, and its diuretic action lowers body water, which can reduce tear volume. |
| Strength of evidence | Emerging. Based on the mechanism and on clinical observation. Notably it is prescribed off label for acne in exactly the young female group now reporting more dry eye. |
| Typical presentation | A mixed picture of evaporative and aqueous deficient dry eye. |
| Clinical note | It is often paired with a topical retinoid for acne, which can compound the risk to the ocular surface. |
| Products | Retinol, retinaldehyde, tretinoin (Retin A), adapalene, and tazarotene, found in serums, creams, and eye area products |
| Common uses | Acne, anti aging skin care, and hyperpigmentation |
| How it affects the eye | Retinoids change how the meibomian glands behave. They encourage abnormal keratinization at the gland openings, reduce oil production, and can shrink the glands themselves. Product applied close to the lid margin can also migrate onto the ocular surface. |
| Strength of evidence | Moderate for prescription strength retinoids and emerging for cosmetic retinol, extrapolated in part from the oral isotretinoin data. |
| Typical presentation | Meibomian gland dropout, an irritated lid margin, and evaporative dry eye. |
| Clinical note | Patients should keep every retinoid product well away from the lid margin and lash line. |
| Drug type | An oral retinoid, chemically 13 cis retinoic acid |
| Common uses | Severe or treatment resistant acne |
| How it affects the eye | This is the best documented of the group. It causes meibomian gland atrophy, reduces the amount of oil and changes its quality, and inflames the lid margin. The effect is dose related. |
| Strength of evidence | Strong and well established. It is the classic drug cause of medication related dry eye. |
| Typical presentation | Blepharoconjunctivitis, very dry eyes, and contact lens intolerance, often appearing during and after a course. |
| How often | Ocular surface symptoms are reported in a large share of users, commonly cited in the range of 20 to 50 percent depending on dose and study. |
| Clinical note | Symptoms often improve after the course ends, but the meibomian gland changes can persist in some patients. |
The broader picture: drug groups that worsen dry eye
| Drug group | Examples | How it worsens dry eye | Relative frequency |
|---|---|---|---|
| Antihistamines | Diphenhydramine, cetirizine, loratadine, chlorpheniramine | Anticholinergic drying of tears and mucous membranes | Very common |
| Bladder anticholinergics | Oxybutynin, tolterodine, solifenacin | Block cholinergic stimulation of the lacrimal gland, reducing tear secretion | Common |
| Antidepressants | Amitriptyline and other tricyclics, sertraline, fluoxetine | Anticholinergic effect lowers tear production | Common |
| Diuretics | Hydrochlorothiazide, furosemide | Reduce total body water and tear volume | Common |
| Beta blockers | Oral atenolol and metoprolol, topical timolol drops | Reduce tear production and protective tear proteins | Moderate |
| Preserved glaucoma drops | Any drop containing benzalkonium chloride | The preservative is toxic to the ocular surface with chronic use | Common in glaucoma patients |
| Retinoids | Isotretinoin, topical tretinoin | Meibomian gland atrophy and reduced oil | Common with isotretinoin |
| Antiandrogens and hormonal agents | Finasteride, spironolactone, some oral contraceptives, hormone therapy | Lower the androgen support the tear glands depend on | Emerging |
| Decongestants | Pseudoephedrine, phenylephrine | Sympathomimetic drying of the surface | Moderate |
| Antipsychotics | Many agents with anticholinergic activity | Reduce tear production | Moderate |
| Proton pump inhibitors | Omeprazole and similar drugs | Linked to dry eye in large population studies, mechanism not fully clear | Emerging but notable |
| Antiarrhythmics | Amiodarone | Corneal deposits and surface disturbance | Uncommon but important |
| Cancer therapies | Certain chemotherapy, targeted, and hormonal agents | Damage the tear glands and ocular surface | Variable |
| Opioids | Various | Reduce reflex tearing | Underrecognized |
A few honest cautions about the numbers.
Dry eye already affects roughly 5 to 15 percent of adults in the United States, so it is often hard to blame any single medication in a given patient. Polypharmacy, meaning several drugs taken together, is the most common driver of medication related dry eye, and the risk rises with age and with the number of medications a person takes.
The DREAM study confirmed that antihistamines, corticosteroids, and seizure medications were tied to more severe dry eye signs and symptoms even after accounting for other conditions. A large Dutch study of 79,606 people found that most drug groups tested were associated with dry eye symptoms, though much of that link was explained by underlying illness. After correction, proton pump inhibitors, glaucoma medications, and anticholinergics showed the strongest independent associations.
References
Downie LE, Ng SM, Lindsley KB, Akpek EK. Omega 3 and Omega 6 Polyunsaturated Fatty Acids for Dry Eye Disease. Cochrane Database of Systematic Reviews. 2019;12:CD011016.
McCann P, Abraham AG, Mukhopadhyay A, et al. Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States. JAMA Ophthalmology. 2022;140(12):1181 to 1192.
Clayton JA. Dry Eye. New England Journal of Medicine. 2018;378(23):2212 to 2223.
Guo M, Diaz GM, Yu Y, et al. Association Between Systemic Medication Use and Severity of Dry Eye Signs and Symptoms in the DREAM Study. The Ocular Surface. 2024;32:112 to 119.
Wolpert LE, Snieder H, Jansonius NM, et al. Medication Use and Dry Eye Symptoms: A Large, Hypothesis Free, Population Based Study in the Netherlands. The Ocular Surface. 2021;22:1 to 12.
Blog version for Eyedoc2020
Eyedoc2020
Dry Eye Disease Is Underreported, and These Medications Are Quietly Making It Worse
Dry eye disease is dramatically underreported in the United States and across the world, and I expect the numbers to keep rising for years. The cause is closer than most people realize.
We are addicted to our screens, and children may be the most vulnerable of all. Every scroll delivers a small hit of dopamine, and as we chase it we stop blinking fully. Over time this trains the brain to blink less often. A complete blink is what milks the essential oil from the meibomian glands along the eyelid margin. When blinking slows, that oil stops flowing, the tear film destabilizes, and the ocular surface begins to break down. For this reason I do not expect the rates to plateau. I expect them to skyrocket.
Patients travel to see me from around the world for dry eye disease, and the concern grows sharper around surgery. Before and after cataract or glaucoma procedures, patients want to know their risk of chronic dry eye, often because they already know someone living with the symptoms.
The pattern that has struck me most in recent years is the wave of young patients in their twenties who develop dry eye after starting medications that are seldom listed as causes in the published literature. Isotretinoin, known as Accutane, is the familiar culprit. The quieter ones are finasteride and spironolactone. Teasing apart how much comes from the drug and how much comes from heavy screen use, which I define here as more than four hours a day, is genuinely difficult. Even so, there is credible evidence that these medications worsen dry eye on their own, before any screen time is added.
My advice is direct. If you notice any symptoms of dry eye disease, see a dry eye specialist promptly. Early treatment protects the meibomian glands we cannot easily replace.
What follows is a clear summary of four medications that can cause or worsen dry eye, and then a wider table of the drug groups known to make it worse.
Four medications worth knowing about
| Drug type | A 5 alpha reductase inhibitor |
| Common uses | Enlarged prostate (Proscar, 5 mg) and male pattern hair loss (Propecia, 1 mg) |
| How it affects the eye | It blocks the conversion of testosterone to dihydrotestosterone, lowering androgen signaling. Androgens are essential for healthy meibomian and lacrimal gland function, so reduced androgen activity can drive meibomian gland dysfunction and lower both the oil and the water in the tear film. |
| Strength of evidence | Emerging. Supported by case reports and by our understanding of how androgens govern the tear glands. Not yet named in most standard dry eye references. |
| Typical presentation | Evaporative dry eye from meibomian gland dysfunction, with burning, fluctuating vision, and symptoms that worsen at the screen. |
| Clinical note | Symptoms can linger in some patients even after the drug is stopped, part of what patients online describe as post finasteride syndrome. |
| Drug type | An aldosterone antagonist and androgen receptor blocker, also a potassium sparing diuretic |
| Common uses | Hormonal acne, especially in young women, along with hirsutism, polycystic ovary syndrome, high blood pressure, and heart failure |
| How it affects the eye | It works through two routes. It blocks androgen receptors, removing the androgen support that the meibomian and lacrimal glands rely on, and its diuretic action lowers body water, which can reduce tear volume. |
| Strength of evidence | Emerging. Based on the mechanism and on clinical observation. Notably it is prescribed off label for acne in exactly the young female group now reporting more dry eye. |
| Typical presentation | A mixed picture of evaporative and aqueous deficient dry eye. |
| Clinical note | It is often paired with a topical retinoid for acne, which can compound the risk to the ocular surface. |
| Products | Retinol, retinaldehyde, tretinoin (Retin A), adapalene, and tazarotene, found in serums, creams, and eye area products |
| Common uses | Acne, anti aging skin care, and hyperpigmentation |
| How it affects the eye | Retinoids change how the meibomian glands behave. They encourage abnormal keratinization at the gland openings, reduce oil production, and can shrink the glands themselves. Product applied close to the lid margin can also migrate onto the ocular surface. |
| Strength of evidence | Moderate for prescription strength retinoids and emerging for cosmetic retinol, extrapolated in part from the oral isotretinoin data. |
| Typical presentation | Meibomian gland dropout, an irritated lid margin, and evaporative dry eye. |
| Clinical note | Patients should keep every retinoid product well away from the lid margin and lash line. |
| Drug type | An oral retinoid, chemically 13 cis retinoic acid |
| Common uses | Severe or treatment resistant acne |
| How it affects the eye | This is the best documented of the group. It causes meibomian gland atrophy, reduces the amount of oil and changes its quality, and inflames the lid margin. The effect is dose related. |
| Strength of evidence | Strong and well established. It is the classic drug cause of medication related dry eye. |
| Typical presentation | Blepharoconjunctivitis, very dry eyes, and contact lens intolerance, often appearing during and after a course. |
| How often | Ocular surface symptoms are reported in a large share of users, commonly cited in the range of 20 to 50 percent depending on dose and study. |
| Clinical note | Symptoms often improve after the course ends, but the meibomian gland changes can persist in some patients. |
The broader picture: drug groups that worsen dry eye
| Drug group | Examples | How it worsens dry eye | Relative frequency |
|---|---|---|---|
| Antihistamines | Diphenhydramine, cetirizine, loratadine, chlorpheniramine | Anticholinergic drying of tears and mucous membranes | Very common |
| Bladder anticholinergics | Oxybutynin, tolterodine, solifenacin | Block cholinergic stimulation of the lacrimal gland, reducing tear secretion | Common |
| Antidepressants | Amitriptyline and other tricyclics, sertraline, fluoxetine | Anticholinergic effect lowers tear production | Common |
| Diuretics | Hydrochlorothiazide, furosemide | Reduce total body water and tear volume | Common |
| Beta blockers | Oral atenolol and metoprolol, topical timolol drops | Reduce tear production and protective tear proteins | Moderate |
| Preserved glaucoma drops | Any drop containing benzalkonium chloride | The preservative is toxic to the ocular surface with chronic use | Common in glaucoma patients |
| Retinoids | Isotretinoin, topical tretinoin | Meibomian gland atrophy and reduced oil | Common with isotretinoin |
| Antiandrogens and hormonal agents | Finasteride, spironolactone, some oral contraceptives, hormone therapy | Lower the androgen support the tear glands depend on | Emerging |
| Decongestants | Pseudoephedrine, phenylephrine | Sympathomimetic drying of the surface | Moderate |
| Antipsychotics | Many agents with anticholinergic activity | Reduce tear production | Moderate |
| Proton pump inhibitors | Omeprazole and similar drugs | Linked to dry eye in large population studies, mechanism not fully clear | Emerging but notable |
| Antiarrhythmics | Amiodarone | Corneal deposits and surface disturbance | Uncommon but important |
| Cancer therapies | Certain chemotherapy, targeted, and hormonal agents | Damage the tear glands and ocular surface | Variable |
| Opioids | Various | Reduce reflex tearing | Underrecognized |
A few honest cautions about the numbers.
Dry eye already affects roughly 5 to 15 percent of adults in the United States, so it is often hard to blame any single medication in a given patient. Polypharmacy, meaning several drugs taken together, is the most common driver of medication related dry eye, and the risk rises with age and with the number of medications a person takes.
The DREAM study confirmed that antihistamines, corticosteroids, and seizure medications were tied to more severe dry eye signs and symptoms even after accounting for other conditions. A large Dutch study of 79,606 people found that most drug groups tested were associated with dry eye symptoms, though much of that link was explained by underlying illness. After correction, proton pump inhibitors, glaucoma medications, and anticholinergics showed the strongest independent associations.
References
Downie LE, Ng SM, Lindsley KB, Akpek EK. Omega 3 and Omega 6 Polyunsaturated Fatty Acids for Dry Eye Disease. Cochrane Database of Systematic Reviews. 2019;12:CD011016.
McCann P, Abraham AG, Mukhopadhyay A, et al. Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States. JAMA Ophthalmology. 2022;140(12):1181 to 1192.
Clayton JA. Dry Eye. New England Journal of Medicine. 2018;378(23):2212 to 2223.
Guo M, Diaz GM, Yu Y, et al. Association Between Systemic Medication Use and Severity of Dry Eye Signs and Symptoms in the DREAM Study. The Ocular Surface. 2024;32:112 to 119.
Wolpert LE, Snieder H, Jansonius NM, et al. Medication Use and Dry Eye Symptoms: A Large, Hypothesis Free, Population Based Study in the Netherlands. The Ocular Surface. 2021;22:1 to 12.
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