Incorporating screening for chronic pain comorbidities into routine dry eye evaluations may support earlier recognition of pain-associated clinical phenotypes.
Several large studies have shown overlaps between ocular discomfort and chronic pain conditions (CPCs) due to central sensitization, altered nociceptive modulation, and high rates of non-pain CNS-mediated symptoms including mood and sleep. Chronic pain conditions are strongly associated with dry eye disease and eye care professionals should consider the diagnosis as a risk factor for the evaluation and management of dry eye disease (DED), according to findings in the American Journal of Ophthalmology.
A retrospective cohort study of adults (ages 18+) with CPC (659,892) and without CPC (1,497,893) from the TriNetX Analytics Network (2005–2025) was performed using ICD-10-CM, Systematized Nomenclature of Medicine, and Current Procedural Terminology codes. Researchers sought to determine the association between the incidence of DED and prescription-requiring DED in patients with CPCs
Both outcomes were evaluated at 1, 2, and 3 months following the index visit and defined as a new diagnosis of dry eye syndrome or keratoconjunctivitis sicca and the initiation of either cyclosporine or lifitegrast. The researchers calculated risk ratios (RR) with 95% confidence intervals. Time-to-event analyses were conducted using Kaplan–Meier curves and multivariable Cox proportional hazards models
Incorporating screening for pain comorbidities into DED evaluation may improve risk stratification, guide earlier recognition of pain-associated phenotypes, and support more individualized management strategies for patients with underlying CPCs
The report indicates that patients with at least 1 CPC diagnosis had a significantly higher risk of developing DED than controls at all follow-up intervals. At 1 year, incident DED occurred in 3.34% of the CPC cohort compared with 0.72% (RR 4.64; 95% CI, 4.49–4.81; P<.0001). At 3 years, cumulative incidence increased to 7.16% compared with 1.50% (RR 4.78; 95% CI, 4.66–4.89; P <.0001).
Additionally, DED requiring a pharmaceutical prescription was also more common in the CPC cohort at 3 years (0.79 vs 0.30%; RR 2.60; 95% CI, 2.45–2.75). In multivariable Cox regression, CPCs were independently associated with increased hazard of incident DED (hazard ratio 4.85; 95% CI, 4.76–4.94; P <.0001). The validation cohort of cataract patients (506,763) yielded similar results
“Incorporating screening for pain comorbidities into DED evaluation may improve risk stratification, guide earlier recognition of pain-associated phenotypes, and support more individualized management strategies for patients with underlying CPCs,” according to the researchers
Study limitations include its retrospective nature, possible inaccuracies in large database coding, an inability to make generalizations due to populations with less access to healthcare, possible residual confounding from unmeasured factors, the failure to exclude patients with a history of cataract surgery, and the use of CPC exposure as a binary variable. Furthermore, EHR data did not include information regarding symptom severity, ocular surface findings, and pain phenotyping, which prevented categorization of patients by dry eye type, deficient vs inflammatory vs pain dominant.
Berzack S, Shmushkevich SB, Zhang C, Felix ER, De Lott LB, Galor A. Risk of incident dry eye disease among patients with chronic pain conditions. Am J Ophthalmol. Published online July 17, 2026. doi:10.1016/j.ajo.2026.07.025
