Addressing geographic variation in dry eye disease care requires patient-centric approaches

Dry eye disease (DED) is a highly prevalent condition, estimated to affect up to 35% of the global population,¹ and is associated with adverse effects on activities of daily living and overall quality of life. While the underlying biology, pathology and symptomology of DED are well understood, much less is known about how patients experience DED and the factors that shape their treatment journey. Gaining insight into the patient experience is essential for overcoming the barriers that leave DED underdiagnosed and undertreated despite its high prevalence and known impacts.

A recent multinational survey (Needs Unmet in Dry Eye: Symptoms, Treatment and Severity [NESTS]) was undertaken to fill a crucial gap in our understanding of the DED patient experience and to provide actionable insights to help address unmet DED needs. NESTS was conducted in five countries (France, Germany, Poland, Saudi Arabia and the United Kingdom) and comprised 5,152 participants (2,580 from the general population and 2,572 with self-reported dry eye). Participants completed an online questionnaire consisting of a maximum of 116 questions (inclusive of sub-questions that were asked/not asked based on response to a prior question) and five additional background questions. Most questions had defined answers from which participants selected, and there was an opportunity, where relevant, to provide additional responses. The general population survey was conducted in February and March of 2025, and the dry-eye population was surveyed in March and April of 2025. Study data were reported as a percentage of responders, and no statistical analyses were performed.

Key NESTS findings

Patients’ Normalization of DED Symptoms Contributes to Delay in Seeking Care

Survey results show that almost one-third of respondents waited more than 6 months from symptom onset to their initial consultation with an HCP, and approximately 20% waited more than 1 year. The most common reason that patients delayed consulting with an HCP was their belief that their symptoms were not severe enough to warrant professional attention (32%-49%) (Table).

Additionally, many study respondents attributed their DED symptoms to behavioural (computer screen time, eye strain, make-up, contact lens use), physiological (ageing, allergies, decreased/lack of tear production), or environmental (dry air/climate heating, air conditioning) factors rather than recognizing them as signs of disease. Patients’ attribution of symptoms to non-DED causes contributes to the normalization and acceptance of symptoms as inevitable, rather than as disease-related outcomes that can be addressed with effective treatment.

Consistent with the belief that DED symptoms are the normal consequence of demographic, lifestyle, or environmental factors rather than evidence of a treatable disease is the high rate of self-treatment reported in the survey. At least 70% of respondents with DED had used an OTC product at least once, most commonly lubricant eye drops. Most also had tried other approaches to resolve their symptoms, including drinking more water (29%-46%), cleaning eyelids (12%-24%), avoiding smoke (24%-41%) and avoiding air conditioning (17%-36%).

Educational initiatives that raise awareness of the causes, effects and potential treatments for DED may help to overcome this normalization of disease symptoms and encourage more people to see an eye care professional. This could address the persistent underdiagnosis and undertreatment of DED and increase acceptance of DED as a significant yet treatable condition.

Patients adapt to DED without recognizing disease burden

It is interesting to note that even as respondents downplayed the need for or value of seeking professional care and attempted to address symptoms on their own, more than 80% reported modifying behaviour due to DED. This was primarily reflected in limiting screen time (26%-48%) and keeping eye drops on hand (35%-51%). Up to 25% of respondents also reported that DED negatively affected their work productivity and driving habits, as well as sunscreen use (42%-65%) and time spent reading (43%-59%).

Similarly, although nearly half of respondents indicated they did not believe their symptoms were severe enough to see an HCP, the vast majority experienced symptoms at least once daily or several times a week (82%-87%). DED symptoms were reported as severe in up to 35% of respondents, while up to 26% found their symptoms very bothersome (Figure).

These findings highlight a critical disconnect between patients’ perceptions that their symptoms don’t warrant professional intervention and the real impact that these symptoms have on their daily lives. They also suggest that patients are making adaptations in their daily lives to accommodate the effects and limitations of DED, rather than trying to correct the problem.

From a clinical standpoint, this disconnect underscores the importance of asking patients specific questions about their daily activities and quality of life rather than focusing on perceived symptom severity. Conversations focused on changes to screen time use, contact lens wear, use of OTC therapies and quality-of-life parameters will be more informative and better enable interventions that address these challenges and enable patients to live their lives more fully.

New Insights into the DED Patient Journey

While the individual data points in our survey provide important insights into specific factors that influence how patients with DED manage their disease, collectively they paint a picture of a patient journey that is frequently complicated by detours and potholes.

As noted above, many patients never consider seeking treatment because they don’t think their symptoms are severe enough to warrant professional attention, assume their symptoms can’t be addressed or adapt their behaviours to accommodate symptoms rather than trying to correct the underlying cause of disease. These findings suggest that disease awareness and education initiatives, as well as strategies to address broader health system challenges, are important for removing barriers that prevent patients with DED from receiving care that can improve their symptoms and quality of life.

Another important takeaway from the survey is patients’ lack of satisfaction with the care they receive once they have taken the initiative to seek professional treatment for their DED symptoms. The extent to which this dissatisfaction results from poor communication between patients and healthcare providers (HCPs) or HCPs’ lack of knowledge about DED symptoms, treatment options or how to individualize therapy based on each patient’s concerns and goals was not addressed in this survey. Future studies designed to assess these factors will be important for identifying and mitigating the obstacles that lead to suboptimal patient experiences. Ensuring that HCPs understand and can effectively communicate disease and treatment information in ways that resonate with each individual patient is essential for improving patient satisfaction and DED outcomes.

Survey results indicate that unmet expectations around dosing frequency and duration, therapeutic efficacy and safety profiles of prescription DED therapies contribute to patients’ dissatisfaction with their clinical experiences. Here again, open and candid conversation between patients and HCPs is essential for aligning expectations and potential outcomes at the start of treatment. Additionally, incorporating patients’ priority expectations into treatment selection equally important in improving patients’ treatment experiences and satisfaction with treatment outcomes. For example, understanding the relative importance of dosing frequency, duration of symptom relief or overall efficacy in reducing symptom frequency/severity may help to identify the therapy that best meets an individual’s treatment goals. Similarly, understanding that these goals may vary from one patient to another is critical to developing individualized treatment plans that are most likely to satisfy each patient’s needs.

Practical Approaches to Improving the DED Patient Experience

While clinical signs are an essential part of DED diagnosis and treatment, patients’ symptoms and quality of life are equally important considerations. Candid communication with patients is essential to understanding their experiences. This can be achieved by integrating the following into routine care in both the eye care professional and broader HCP care settings:

• Proactively ask patients if they are experiencing any symptoms associated with DED rather than waiting for them to broach the subject, and listen carefully to their responses.
• Carefully assess patients reporting DED symptoms to determine if they are due to DED or other causes; if needed, refer patients to appropriate care providers for evaluation and diagnosis.
• Take the time to understand how DED shapes patients’ lives by asking not only about the frequency and severity of symptoms but also how these symptoms affect their daily lives. It is also important to understand each patient’s exposure to environmental factors (screen time, allergens, etc.) and to determine if and how these factors can be moderated or mitigated to reduce DED symptoms.
• Help establish realistic expectations about living with DED by educating patients about the realities of living with a chronic condition such as DED. This includes identifying strategies to mitigate factors within their control and selecting treatment options that meet patients’ long-term treatment needs and goals.
• Individualize treatment based on the underlying disease mechanisms (as highlighted in the TFOS DEWS III (Tear Film and Ocular Surface Society Dry Eye Workshop III) report, rather than using the same approach for every patient.
• Broaden the adoption of modern diagnostic tools, such as meibography and tear osmolarity testing, to better understand the disease and guide treatment decisions.
• Evaluate all patients for DED before every eye surgery to avoid refractive surprises and healing problems.
• Prioritize closing the gap between what patients experience and what clinicians recognize.
• Make improving the DED patient experience a primary goal of everyday practice.

Conclusions

Results from the multinational NESTS study highlight the need for patient experience to play a greater role in DED awareness, diagnosis and treatment. Individualized treatment must start at the beginning of the patient journey, and even artificial tears need to be strategically chosen based on each patient’s specific needs. The development of education and access programmes for DED must be informed by the perspectives of the patients these programmes seek to serve. Clinicians treating DED should prioritize learning from their patients and improving the patient journey as much as they focus on educating patients about the disease.

Reference
1. Xiao K, Li L, Zhang X, et al. Global prevalence of dry eye: a systematic review and meta-analysis. Cont Lens Anterior Eye. 2025;49(2):102627. doi:10.1016/j.clae.2026.102627