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Dry eye disease rarely presents as a straightforward clinical puzzle. Some patients report burning, grittiness and blurred vision despite showing few visible signs; others have significant corneal damage yet feel little discomfort. In a conversation with Dr. Darryl Glover, dry eye specialist and researcher Dr. Kaleb Abbott explains why this disconnect matters—and how recognizing it can lead to more thoughtful, individualized care.
Topics Covered :
What Really Drives Treatment Decisions?
Dr. Abbott, an assistant professor at the University of Colorado School of Medicine, examined this question in the study What Guides Treatment Decisions in Dry Eye Disease: Signs or Symptoms? His team surveyed 208 optometrists and ophthalmologists, presenting clinical scenarios designed to reveal how practitioners respond when signs and symptoms conflict.
Only 1.1% of ophthalmologists and 5.2% of optometrists said the two frequently correlate. When patients reported moderate to severe symptoms despite having minimal clinical signs, virtually every respondent was at least somewhat likely to begin treatment. Clinicians were also willing to treat asymptomatic patients with significant signs, although symptoms carried greater influence overall.
The same pattern shaped perceptions of success. More practitioners considered treatment successful when symptoms improved without a corresponding change in signs than when clinical findings improved but the patient felt no better.
Symptoms Matter—But So Does Ocular Health
“Symptoms are king,” Dr. Abbott said, noting that pain and discomfort can substantially affect a patient’s quality of life. Still, he cautioned against allowing symptom relief to overshadow ocular health. Dense staining, corneal desiccation and epithelial defects may increase the risk of infection or ulceration, even when the patient reports feeling well.
Patients with neurotrophic keratitis illustrate this danger. Damaged or impaired corneal nerves may fail to signal pain despite serious surface disease. By contrast, people with neuropathic ocular pain may experience severe symptoms with few visible findings.
The clinician’s task, therefore, is not to choose between signs and symptoms, but to understand what each may be revealing.
Dry Eye Is Not Always About Dryness
The language surrounding the disease can further complicate diagnosis. According to the survey, clinicians ranked burning or stinging, grittiness, fluctuating vision and foreign-body sensation above dryness itself. Watering ranked sixth.
That finding supports Dr. Glover’s practice of training technicians to ask specifically about burning, grittiness and blurred vision instead of simply asking whether a patient has dry eye. Patients may not recognize their experiences under the condition’s familiar name, making precise questions essential.
On examination, both professions prioritized ocular surface staining and tear breakup time. Optometrists, however, placed greater emphasis on eyelid abnormalities, including telangiectasia, Demodex blepharitis, meibomian gland dropout and poor meibum quality.
Looking Beyond the Eye
Some of the strongest predictors of symptom severity may be non-ocular. Dr. Abbott pointed to chronic pain syndromes, migraines, fibromyalgia, poor sleep, traumatic brain injury, anxiety and depression as factors that may heighten pain perception. Symptoms can arise anywhere along the trigeminal nerve pathway, not solely at the corneal surface.
This broader understanding challenges the conventional stepladder approach in which every patient receives the same sequence of therapies. Instead, Dr. Abbott urged clinicians to remain “naturally curious yet skeptical,” take more complete medical and surgical histories, and investigate suspicious patterns such as unilateral symptoms or pronounced sign-symptom discordance.
The episode’s central lesson is clear: dry eye care begins with listening, but it cannot end there. By combining the patient’s experience with clinical findings, neurologic considerations and broader health history, eye care professionals can move beyond labels and treat the person behind the symptoms.
