Mixed signals and mounting frustrations: ophthalmologists on dry eye disease

A recent survey of practicing ophthalmologists conducted by Ophthalmology Times revealed a clinical landscape defined by diagnostic ambiguity, therapeutic limitation, and systemic friction. Although the survey was limited to a sample size of 17 physicians, the responses underscore that despite a growing armamentarium of treatment options, dry eye disease (DED) remains one of the most challenging and contested conditions in ophthalmic practice.

Click here for the Ophthalmology Times: 2026 Dry Eye Disease Survey

A disease without a clean diagnosis

The survey's first major finding concerns how clinicians classify the condition itself. A substantial majority of respondents—71% (n = 12)—said the subtype they most frequently diagnose is mixed-mechanism dry eye, while the remaining 29% (n = 5) identified evaporative, meibomian gland dysfunction (MGD)-predominant disease as their most common presentation. Notably, no respondent identified aqueous-deficient dry eye as their primary diagnosis.

That distribution, while perhaps not surprising to specialists, carries significant implications. Mixed mechanism dry eye resists clean categorization and, by extension, resists clean treatment pathways. As one respondent put it plainly, the issue is one of heterogeneity masquerading as a single disease: "It's not one disease. We need to stop calling it all dry eye."

What patients complain about most

When asked to identify the most commonly reported bothersome symptoms, respondents coalesced around a consistent triad. Fluctuating vision was cited most frequently, appearing in 82% of responses (n = 14), followed by burning or stinging at 76% (n = 13) and foreign body sensation at 71% (n = 12). Ocular fatigue and photophobia were each mentioned by a smaller subset of respondents, while excessive tearing and neuropathic-type pain were cited by a minority.

The prominence of fluctuating vision as the top symptom is clinically notable. Unlike burning or stinging—which patients often associate directly with eye discomfort—fluctuating vision can be misattributed to refractive error or aging, potentially delaying diagnosis or leading patients to pursue unnecessary refractive evaluations before dry eye is considered.

The workup: symptom-based assessment still rules

Respondents were asked to identify the diagnostic tools they routinely include in their dry eye workup, with the option to select all that apply. Tear break-up time (TBUT) was the most universally used tool, cited by 82% of respondents (n = 14), followed closely by ocular surface staining at 76% (n = 13). Symptom-based diagnosis alone—without objective testing—was reported by 65% (n = 11) of respondents as a standard component of their workup.

Questionnaire-based tools such as the Ocular Surface Disease Index (OSDI) were included by 47% of respondents (n = 8), while meibography was cited by 35% (n = 6). Inflammatory marker testing—such as matrix metalloproteinase-9 (MMP-9)—was included by 35% of respondents as well. Tear osmolarity testing appeared in just 12% of responses (n = 2), reflecting its limited adoption in routine practice despite its availability.

The continued reliance on symptom-based diagnosis, even among specialists, reflects a practical reality: objective testing adds time and cost, and not all practices are equipped with the full suite of diagnostic instruments. However, it also raises questions about reproducibility and consistency in how the disease is characterized across clinical settings.

The treatment landscape: cyclosporine leads, but the field is broadening

On the prescription treatment side, respondents were asked to identify their most frequently prescribed therapies, selecting up to 3. Topical cyclosporine remained the most commonly cited, appearing in 65% of responses (n = 11). Perfluorohexyloctane ophthalmic solution (Miebo; Bausch + Lomb) was the second most frequently mentioned, cited by 59% of respondents (n = 10), followed by lifitegrast ophthalmic solution 5% (Xiidra; Novartis) at 53% (n = 9).

A substantial portion of respondents—41% (n = 7)—also indicated that they primarily recommend over-the-counter (OTC) therapies, either as a standalone approach or as part of their top-3 selection, underscoring that many practitioners still begin and, in some cases, end their management at the non-prescription level. Loteprednol etabonate ophthalmic suspension (short-term) was cited by 24% (n = 4), while varenicline solution nasal spray (Tyrvaya; Viatris) and autologous serum tears were each mentioned by a small subset of respondents. Acoltremon (Klarity-C; OSRX Pharmaceuticals) was cited by 18% (n = 3).

The escalation trigger: persistence over progression

When asked what primarily triggers their decision to escalate therapy beyond artificial tears, the majority of respondents—59% (n = 10)—identified persistent symptoms despite OTC therapy as their primary catalyst. Corneal staining progression was cited by 24% (n = 4) as the main driver, while patient dissatisfaction or quality-of-life concerns prompted escalation for 18% (n = 3). One respondent cited meibomian gland atrophy as their primary trigger.

The fact that symptom persistence—a largely subjective measure—is the dominant escalation trigger for most respondents again underscores the degree to which DED management remains tethered to patient-reported outcomes rather than objective disease markers. For practitioners who escalate primarily on corneal staining or gland atrophy, there is at least a tangible, measurable threshold. For the majority, however, the decision to escalate is inherently more variable.

A divided view on emerging mechanism-based therapy

The survey also explored respondents' perspectives on small molecule inhibition of the reactive aldehyde species pathway (RASP)—an emerging therapeutic mechanism under investigation in DED. When asked whether they believe this approach offers a clinically meaningful differentiation, the majority remained in a holding pattern: 59% (n = 10) said, "possibly, but awaiting more real-world data." An additional 12% (n = 2) indicated they were unfamiliar with the mechanism entirely, while 24% (n = 4) said yes, characterizing it as a meaningful mechanism-based advance. Just one respondent (6%) said no, viewing it as comparable to existing therapies.

The cautious-but-open posture among the majority reflects a broader pattern in how the field approaches novel mechanisms—interest without yet sufficient clinical evidence to drive adoption. For companies developing RASP inhibitors, building a body of real-world data will likely be as important as trial outcomes in winning over practicing ophthalmologists.

Where the field is falling short

Respondents were asked to identify the greatest unmet need in dry eye management in their practice. The responses were notably varied, with no single answer commanding a clear majority. Faster onset of action was cited most frequently, appearing in 35% of responses (n = 6). Clearer treatment algorithms were identified as the top unmet need by 29% of respondents (n = 5). Better reimbursement and affordability were the primary concern for 12% (n = 2), while greater efficacy, improved long-term tolerability, more durable MGD-directed therapies, and an actual cure were each cited by individual respondents.

Two respondents highlighted the reimbursement and prior authorization burden in strikingly direct terms. "Preauthorizations—my staff gets mad, but worse, my patients get mad and blame me and my staff for not filling out paperwork," one respondent wrote. "It is just super frustrating and limits my prescribing because I do not want patients angry at me."

Another offered a broader systems-level critique: "All topical pharmaceutical therapies place burdens of cost, long-term compliance, side effects, and speed of efficacy on the patient, who may or may not feel or see benefits outweighing these burdens soon enough to motivate adherence to therapy. They also place burdens on practices with coverage, fail-first guidelines from payers, prior authorizations, and denials, with no reimbursement to make up for it."

The biggest frustration, in 1 sentence

The final survey question asked respondents to summarize their single greatest frustration with dry eye management in one sentence. The answers ranged from the personal to the systemic, but several themes emerged with clarity: the unpredictability of treatment response, the chronicity of the disease, the inadequacy of current therapies, and the structural barriers that limit access to the ones that exist.

"Inability to predict likelihood of response to different therapeutic regimens," wrote one respondent—a frustration that resonates across the broader specialty. Another cited the overcrowding of the therapeutic space paired with patient cost: "Too many options and costly [for] patients." One respondent's frustration was directed outward toward the broader care continuum: "So many patients with mixed-mechanism dry eye [are] poorly managed by optometrists and general ophthalmologists." Another lamented the intractability of the condition itself: "It affects vision, and it's super frustrating to treat."

Taken together, the survey paints a picture of a specialty wrestling with a disease that is too heterogeneous to treat uniformly, too chronic to satisfy easily, too burdened by payer friction to manage efficiently, and too symptom-driven to benchmark objectively. The answers also suggest that the next meaningful advance in dry eye care may not come from a single new molecule but from a combination of faster-acting therapies, better diagnostic standards, clearer prescribing guidance, and a health system better equipped to support both patients and the clinicians treating them.

This survey was conducted by Ophthalmology Times among 17 practicing ophthalmologists in February–March 2026. All responses were collected anonymously.