November 2015




Cornea editors corner of the world

Taking a closer look at dry eye and depression

by Vanessa Caceres EyeWorld Contributing Writer


Clara Chan, MD

While most ophthalmologists understand dry eye to be a chronic disease, they may not realize that there is another chronic disease that has a connection to dry eye. Significant associations have been reported in the literature between dry eye disease and depression. One such study, which screened more than 460,000 patients, found that those with dry eye disease were almost 3 times more likely to suffer from anxiety or depression. As clinicians, we tend to focus on optimizing patients dry eye symptoms medically, but it is important to realize that these patients often also need compassion, empathy, and hope. Certain anti-depressants can make the eyes more dry as well, so a vicious cycle ensues. Communication with the prescribing physician has an important role in these cases.

This months Cornea editors corner of the world focuses on the connection between depression and dry eye. Anat Galor, MD, Francine Rosenberg, PsyD (psychologist), and Rebecca Petris (patient advocate) provide a multi-disciplinary perspective and pearls for how ophthalmologists can help their patients with dry eye disease who may also suffer from depression.

Clara C. Chan, MD, FRCSC, FACS, cornea editor

Woman in depression

How medications and daily living with dry eye can be linked to mood disorders

Ophthalmologists arent trained mental health professionalsbut they need to have some knowledge about depression in dry eye patients, considering the link often found between the two conditions.

In fact, several studies published in 2015 have focused on the connection between depression and dry eye disease, including a report published in Cornea in September that used a depression inventory and found a significant scoring difference between dry eye cases and controls.1 Dry eye symptoms were measured with the symptom burden tool and the Ocular Surface Disease Index tool. The study calls for prospective research to better understand the mechanisms underlying depression and dry eye symptoms.

A population-based study also published in Cornea this year focused on a nationally representative sample of Korean women and found that subjects diagnosed with dry eye disease were more likely to be experiencing psychological stress, a depressive mood, and anxiety/depression problems.2

Another population-based study published in March found a statistically significant association between dry eye disease and depression as well as anxiety.3

Focus on the meds

One obvious link is that certain antidepressants tend to be drying, said Anat Galor, MD, staff physician, Miami Veterans Affairs Medical Center, and associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, Miami. When she and fellow researchers examined the scope of dry eye in veterans, they found that several systemic medications, including antidepressants, were associated with an increased risk for dry eye.4 Some medications can trigger dryness, and this should be discussed with the prescriber, said Francine Rosenberg, PsyD, Morris Psychological Group, Parsippany, N.J. One example is medications with anticholinergic effects, which block acetylcholine in the brain and are known to be drying. Even newer antidepressants can affect dryness, according to a study published earlier this year in the Journal of Clinical Psychopharmacology.5 Researchers in the study included 54 patients using new antidepressants and 57 controls. Using the Schirmer test and focusing on the medications escitalopram, duloxetine, and venlafaxine, they found that Schirmer test results were significantly lower than in controls. The patients using selective serotonin reuptake inhibitors displayed lower wetting measurements compared with those using serotonin-norepinephrine reuptake inhibitors, which was independent of the duration of antidepressant usage, the researchers wrote. Although ophthalmologists are not typically involved in treating depression, they should always stay vigilant about other systemic conditions a patient is experiencing to consider the effects on the eye, Dr. Galor said. Communication with the prescribing doctor can help explore medication alternatives if necessary. An awareness of drugs that may lead to dry eye can help ophthalmologists and other eyecare specialists manage the problem, researchers have concluded.5

How dry eye may lead to depression

The other link between dry eye and depression is when the problems of daily life associated with moderate or severe dry eye can lead someone to feel bad. This is similar to any other chronic disease, Dr. Rosenberg said.

Dealing with a chronic health condition can affect the way someone sees himself or herself and participates in daily activities. A limitation in activity may lead to a gradual withdrawal of pleasurable experiences and a decrease in quality of life, she said. They may worry about keeping their job and financial strains or may become socially withdrawn and lack emotional support. The risk of depression and anxiety increases with the severity of the illness. If the persons experiences with a chronic illness are not validated by others around them, this can worsen the situation, said Rebecca Petris, owner, the Dry Eye Company, Poulsbo, Wash.

Ms. Petris, who has experienced severe dry eye herself, uses her website to help people who have dry eye. Unfortunately, many eye doctors fail to validate the difficulty the patient is facing on a daily basis, no matter how severe the clinical signs, she said. The patient who has severe symptoms without severe signs is much more likely to face dismissive attitudes that can undermine their hope of finding solutions. The effects of depression related to dry eyeor for that matter, any other chronic diseasebecome cyclic as the patient may find it hard to care for themselves effectively, leading to a decrease in medication compliance. That can make the patient feel worse.

A third possibility is that shared susceptibility factors, both genetic and environmental, underlie dry eye and depression. It is well described that certain individuals are more susceptible than others to developing chronic pain states, with one study specifically focusing on shared genetic factors underlying both dry eye and other chronic pain syndromes.6

The link between depression and dry eye isnt always clear cut, Dr. Galor said. Her research found that mental health diagnoses (post-traumatic stress disorder and depression) and their treatments (antidepressants and anxiolytics) remained significantly associated with an increased risk of dry eye.4 Like any other chronic disease, dry eye is a heterogeneous and complex condition, and it is likely that both mental health disorders and their treatments are involved in the pathophysiology of disease, she said.

5 ways to help patients who are depressed

So what should ophthalmologists do if they see a patient with dry eye who does not yet have help from a mental professional? Here are some suggestions: 1. Refer the patient to a psychologist or qualified mental health professional as soon as there are concerns about a mood disorder, Dr. Rosenberg advised. The best results often come from a combination of psychotherapy and medication, she said. When speaking with patients, be aware of quality of life concerns they may mention, such as social withdrawal, fatigue, and decreased concentration, which can all be symptoms of depression, she said.

2. Dont assume only one kind of patient gets depressed over chronic disease. A dry eye crisis is just as likely to emotionally level the most competent, confident people as anyone else, Ms. Petris said. Her anecdotal experience speaking with dry eye patients has found that confident, health-conscious types with no other medical problems may get blindsided the most, as they have always taken care of their health.

3. Validate the patients experiences and feelings, Dr. Rosenberg recommended. Let them know that what they are experiencing can be difficult. A little compassion and empathy will go a long way, Ms. Petris said.

4. Give patients ways to manage their symptoms. Dont say Theres nothing else, Ms. Petris said. Artificial tears, plugs, steroids, and Restasis [cyclosporine, Allergan, Dublin, Ireland] are just scraping the surface, so when they dont solve things, assure your patient that you will work with them to continue trying new avenues. Hope is the most precious commodity to the dry eye patient. 5. Encourage patients to connect with others in a similar situation. For example, Ms. Petris has a free online forum, Dry Eye Talk ( where people can share their dry eye experience and seek out support. There are also support groups for depression and other chronic illnesses online.


1. Hallak JA, Tibrewal S, Jain S. Depressive symptoms in patients with dry eye disease: a case-control study using the Beck Depression Inventory. Cornea. 2015 Sept. 30 [Epub ahead of print].

2. Na KS, Han K, Park YG, Na C, Joo CK. Depression, stress, quality of life, and dry eye disease in Korean women: a population-based study. Cornea. 2015; 34:733738.

3. van der Vaart R, Weaver MA, Lefebvre C, Davis RM. The association between dry eye disease and depression and anxiety in a large population-based study. Am J Ophthalmol. 2015;159:470474.

4. Galor A, Feuer W, Lee DJ, et al. Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United States Veterans Affairs administrative database. Am J Ophthalmol. 2012;154:340346.

5. Koer E, Koer A, et al. Dry eye related to commonly used new antidepressants. J Clin Psychopharmacol. 2015;35:411413.

6. Vehof J, et al. Shared genetic factors underlie chronic pain syndromes. Pain. 2014 Aug;155(8):1562-8.

Editors note: The physicians have no financial interests related to this article.

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