Esen Akpek, MD, on dry eye quality of life, Sjögren disease, and knowing when to escalate treatment

Dry Eye Awareness Month has renewed attention on a condition often dismissed as a minor irritation, even as new survey data document a measurable emotional and functional toll.¹ Esen K. Akpek, MD, professor of ophthalmology, director of the Frances and C. Stephen Foster Center for Ocular Immunology and Inflammation, and chief of the division of ocular immunology at Duke University School of Medicine, has spent much of her career at the intersection of the ocular surface and systemic autoimmune disease, including leadership roles in the TFOS Dry Eye Workshops and clinical trials in dry eye diagnostics. She argues that managing dry eye well means going beyond the ocular surface, drawing out the vision problems patients rarely mention and staying alert to the systemic disease their symptoms may signal.

As previously reported in Ophthalmology Times, Bausch + Lomb's third annual State of Dry Eye survey, conducted online by The Harris Poll in May 2026 among 1000 US adults with dry eye, tied symptom management to improved quality of life, with 73% of respondents who said dry eye affected their stress or anxiety reporting improvement after treatment. Roughly 1 in 3 respondents reported effects on stress or anxiety, and prescription users reported greater gains in self-confidence, productivity, emotional wellbeing, and mood than over-the-counter users. The survey also surfaced striking awareness gaps: 90% did not know dry eye can be associated with menopause, and nearly 8 in 10 did not know it can be linked to autoimmune conditions.¹ In the following Q&A, Akpek expands on the psychosocial and vision-related burden of dry eye, the diagnostic stakes of that autoimmune awareness gap, and the signals that tell her it is time to move a patient beyond artificial tears.

This interview has been lightly edited for length and clarity.

The survey found that roughly 1 in 3 patients say dry eye symptoms affect their stress or anxiety levels, and about 1 in 5 report impacts on self-confidence and emotional wellbeing. Does this psychosocial burden match what you see in your clinic, and how do you incorporate quality-of-life considerations into your dry eye workups?

Esen K. Akpek, MD: These findings are very consistent with what we see in clinical practice. Dry eye disease is often mistakenly viewed as a nuisance, a minor irritation, yet for many patients it is a chronic condition that impacts nearly every aspect of daily life. An under-recognized and underappreciated aspect of dry eye is its effects on vision and vision-related quality of life. Patients frequently describe frustration with fluctuating or blurred vision, difficulty reading, reduced productivity, inability to comfortably use digital devices, and visual fatigue that worsens throughout the day. These functional limitations often translate into anxiety, social withdrawal, and reduced confidence, particularly when symptoms interfere with work, driving, or hobbies.

We and others have demonstrated the close correlation between dry eye and depression and anxiety. One of the challenges is that patients do not always say, "My eyes are dry." Instead, they present with indirect complaints such as not being able to read, eye fatigue, headaches after computer use, or difficulty maintaining concentration while reading. Understanding how dry eye affects quality of life requires asking these functional questions rather than focusing solely on pain or discomfort. We and others have demonstrated that dry eye impairs visual function by reducing image quality and contrast sensitivity. In my practice, assessing quality of life is an integral part of every dry eye evaluation. Beyond documenting symptoms and ocular surface findings, I ask patients how their vision affects reading, screen use, driving, occupational performance, and outdoor and social activities. My research has also focused on reading speed as an objective functional outcome because reading is one of the most visually demanding activities of daily life. We have found that objective measures of visual function can reveal disease burden that is not always captured by traditional symptom questionnaires. Treating dry eye successfully means improving not only the ocular surface, but also restoring patients' ability to function comfortably and confidently in their everyday lives.

Nearly 8 in 10 respondents were unaware that dry eye symptoms can be linked to autoimmune conditions such as Sjögren disease, lupus and rheumatoid arthritis. From your perspective, what are the clinical consequences of that awareness gap—and what should ophthalmologists be doing to close it?

Akpek: This awareness gap has significant clinical implications. For many patients, chronic dry eye is not simply an isolated ocular problem—it may be the earliest manifestation of a systemic autoimmune disease. We have previously demonstrated that approximately 47% of patients with significant, primarily aqueous-deficient dry eye have an underlying disease such as Sjögren disease, rheumatoid arthritis, sarcoidosis, lupus or inflammatory skin disorders such as psoriasis. Sjögren disease is a particularly important example, in which ocular symptoms frequently precede the systemic diagnosis by an average of a decade. Importantly, approximately 1 in 10 patients with clinically significant dry eye have underlying Sjögren disease, and 50% of those patients do not carry the diagnosis at presentation.

Unfortunately, many patients continue to receive only symptomatic treatment with artificial tears while the underlying autoimmune process remains undetected. Delayed diagnosis has important consequences because autoimmune diseases affect multiple organ systems and can lead to irreversible complications if left untreated. Early recognition allows patients to receive appropriate rheumatologic evaluation, systemic management, and multidisciplinary care before significant disease progression occurs. At the Foster Ocular Immunology and Inflammation Center, Duke University School of Medicine, we evaluate and manage these patients in a multidisciplinary fashion with collaborations from rheumatology, dermatology, oncology, etc. Ophthalmologists are uniquely positioned to identify these patients because they are often the first physicians to evaluate individuals with persistent ocular symptoms.

Every patient with significant aqueous-deficient dry eye—particularly those with severe symptoms, markedly reduced tear production, or accompanying complaints such as dry mouth, joint pain, fatigue, or salivary gland enlargement—should prompt consideration of an underlying autoimmune disorder. Collaboration with physicians from other disciplines is essential. Our current research centers around evaluating tear fluid to establish novel biomarkers. As our knowledge of ocular surface immunology advances, I believe ophthalmologists will increasingly play a central role not only in treating dry eye but also in identifying systemic disease at an earlier, more treatable stage and monitoring disease activity reliably.

Respondents on prescription therapy were more likely than OTC-only users to report substantial improvement across self-confidence, productivity, emotional wellbeing, and mood. In your practice, what signals tell you it's time to move a patient beyond artificial tears to prescription treatment?

Akpek: Artificial tears certainly have an important role in providing lubrication of the ocular surface. But they do not address the other mechanisms responsible for chronic dry eye disease such as inflammation and ocular surface innervation. In fact, excessive reliance on frequent water-based artificial tears may dilute and wash away the natural tear components (mucin and meibum) that are critical for maintaining ocular surface health. I generally consider prescription therapy when patients have persistent symptoms despite appropriate use of lubricants, demonstrate objective evidence of ocular surface damage with conjunctival and/or corneal vital dye staining, experience fluctuating vision that interferes with daily activities, or require artificial tears multiple times throughout the day simply to remain comfortable.

The goal is to intervene in a timely manner, certainly before chronic inflammation becomes self-perpetuating and results in progressive ocular surface damage. Modern dry eye management has shifted from simply replacing tears to simultaneously restoring tear film homeostasis and interrupting the inflammatory cycle. By targeting the underlying disease process, and main drivers outlined in the Tear Film and Ocular Surface Society Dry Eye Workshop III (TFOS DEWS III), rather than masking symptoms, prescription therapies can improve not only ocular comfort but also visual function, work productivity, and overall quality of life. Ultimately, our objective is not simply to help patients feel better for a few hours after instilling drops, but to halt and reverse the disease process and restore natural homeostasis of the lacrimal functional unit.

Reference
1. Bausch + Lomb. New Bausch + Lomb data show that addressing dry eye symptoms is associated with improved quality of life, including lower anxiety and increased self-confidence. Press release. Published July 1, 2026. Accessed July 7, 2026. https://www.businesswire.com/news/home/20260701890414/en/