Prevalence of Dry Eye Disease: Causes and Risk Factors

Dry eye disease affects roughly one in three people worldwide, making it one of the most common reasons for an eye doctor visit. A 2025 systematic review and meta-analysis estimated global pooled prevalence at about 35%, though that figure shifts dramatically depending on the diagnostic method used, the population studied, and the region of the world in question. The condition is far more than a minor inconvenience for many who have it, and the web of causes and risk factors behind it is broader than most people realize.

How Common Is Dry Eye, Really?

Prevalence estimates for dry eye disease vary so widely that it can be hard to pin down a single number. A large meta-analysis published in 2025, pooling data from studies across multiple continents, arrived at a global prevalence of about 35%.¹ That number includes people identified by symptoms, clinical signs, or both. A separate Bayesian analysis estimated an overall global prevalence of about 12%, but when the authors applied a combined diagnostic framework that accounts for both signs and symptoms together, their estimate jumped to roughly 30%.² Meanwhile, a U.S.-focused meta-analysis looking specifically at clinically diagnosed dry eye placed the figure much lower, with a summary estimate around 8%.³

Why the enormous range? Dry eye can be identified by what a patient reports (grittiness, burning, fluctuating vision) or by what a clinician measures at the slit lamp (tear break-up time, staining on the cornea, tear volume). These two approaches frequently disagree, which is one of the defining frustrations of the condition. A systematic review found that only about a quarter of individual analyses showed a statistically significant correlation between signs and symptoms, and the vast majority of those correlations were weak.⁴ In practical terms, someone can have a severely uncomfortable eye surface that looks relatively normal under examination, or eyes that show clear clinical damage while the person reports feeling fine. This disconnect means that studies relying on questionnaires tend to produce different prevalence numbers than those using clinical tests.

Geography matters, too. The 2025 meta-analysis found the highest prevalence in Africa, at roughly 44%, and the lowest in North America, at about 21%.¹ The Bayesian analysis also placed Africa’s symptomatic prevalence highest and North America’s lowest, with East Asia showing particularly high rates of clinical signs.² Whether these regional differences reflect genuine biological or environmental variation, differences in study methods, or varying access to care remains an open question.

What Actually Happens in the Eye

The tear film is not just saltwater. It has three interdependent components: a watery (aqueous) layer that provides most of the volume, an oily (lipid) layer on top that slows evaporation, and a mucous layer underneath that helps tears stick to the eye’s surface. Dry eye was historically split into two categories based on which part broke down first. Aqueous-deficient dry eye meant the lacrimal glands were not producing enough of the watery component. Evaporative dry eye meant tears were evaporating too quickly, usually because the oily layer was inadequate.

That clean separation has blurred. Research now shows that a thin aqueous layer shortens tear break-up time even when the lipid and mucin layers are working normally, meaning aqueous deficiency itself can drive evaporation-related problems.⁵ In practice, most people with dry eye have some combination of both mechanisms rather than a pure form of either. Meibomian gland dysfunction, where the oil-producing glands in the eyelids become clogged or atrophied, is recognized as the leading driver of the evaporative type and a major contributor to dry eye overall.⁶

Once the tear film becomes unstable, a self-reinforcing cycle takes hold. Tear instability raises the salt concentration on the eye surface (hyperosmolarity), which triggers inflammation, which damages the cells that maintain the tear film, which makes the tears even less stable.⁷ Breaking into this loop early is easier than stopping it once chronic inflammation has set in, which is part of why dry eye that goes untreated tends to worsen over time.

Sex, Hormones, and Age

Women are more likely to develop dry eye than men at virtually every age. The 2025 global meta-analysis found a prevalence of about 39% in women compared with about 31% in men.¹ The gap widens around menopause, and hormonal shifts are a major reason why. Both estrogens and androgens influence every layer of the tear film, affecting the watery component, the oil layer from the meibomian glands, and the mucin that anchors tears to the surface.⁸ Declining androgen levels appear to be especially relevant, because androgens support meibomian gland function. Hormone replacement therapy has not consistently resolved the problem and in some studies has made it worse, so the hormonal picture is more complicated than simply “replace what is missing.”

Age plays its own role. The 2025 meta-analysis found slightly higher prevalence in people over 40 compared with those under 40, but the difference was modest (about 37% versus 35%).¹ The Bayesian analysis suggested prevalence was lowest around the fifth decade of life and rose roughly in a straight line with each decade afterward.² The combination of declining tear production, accumulated meibomian gland dropout, and the chronic medications that many older adults take all contribute to this age-related rise.

Screens, Blinking, and the Modern Workday

If your eyes feel worse after a long stretch at a computer, the explanation is partly mechanical. When you stare at a screen, you blink less often, and the blinks you do produce tend to be incomplete, meaning the upper lid does not travel all the way down. Each full blink spreads a fresh layer of tears and lipids across the eye surface. Reduced and incomplete blinking allows tears to evaporate faster from the exposed surface, and over time this can initiate the inflammatory cycle that defines dry eye.⁹

Screen use also exposes more of the eye than, say, reading a book on a desk. Your gaze angle is typically higher when looking at a monitor, which increases the amount of ocular surface open to the air. Since tear evaporation is directly proportional to the area of exposed eye, looking straight ahead at a screen is more drying than looking downward at a printed page.¹⁰ The COVID-19 pandemic, which pushed millions of people into sustained screen time at home, was associated with a sharp rise in dry eye prevalence. One meta-analysis found that studies conducted during the pandemic reported dry eye rates around 45%, noticeably higher than pre-pandemic figures.¹

Contact Lenses and Eye Surgery

Contact lens discomfort and dry eye overlap substantially. Wearing a lens splits the tear film into a layer above and below the lens, disrupts its normal distribution, and increases friction between the lens and the eyelid. Over time, this can reduce the density of goblet cells on the conjunctiva, the cells responsible for producing the mucin layer of the tear film, which further destabilizes tears.¹¹ The friction between the lens edge and the tissue lining the inner eyelid can also cause a condition known as lid-wiper epitheliopathy, where the strip of tissue that sweeps across the lens surface with every blink becomes irritated.¹² A large population-based study in the Netherlands confirmed contact lens use as one of the stronger independent risk factors for dry eye.¹³

Refractive surgeries like LASIK carry a well-known risk of post-surgical dry eye. During LASIK, a flap is cut in the cornea, severing the fine nerve fibers that signal the lacrimal gland to produce tears. Research has confirmed an inverse relationship between nerve regeneration after LASIK and dry eye symptoms, meaning patients whose nerves recovered more completely experienced less dryness.¹⁴ This type of post-surgical dry eye is essentially a nerve injury problem. For most patients it resolves within months as the nerves regrow, but a subset experiences persistent symptoms lasting a year or longer.

Autoimmune and Systemic Diseases

Dry eye can be a window into broader systemic disease. Sjögren syndrome, an autoimmune condition in which the immune system attacks moisture-producing glands, is the classic example. Among Americans over 50 with dry eye, roughly one in ten has underlying Sjögren syndrome, and many of those individuals have never been diagnosed.¹⁵ The Dry Eye Assessment and Management study found that participants with Sjögren syndrome had measurably worse clinical signs than those without it, and the same was true for people with rheumatoid arthritis and facial rosacea.¹⁶

Rheumatoid arthritis specifically doubled the rate of developing dry eye in a large matched cohort study, with an adjusted hazard ratio of about 2.0.¹⁷ The Dutch Lifelines study, which followed nearly 80,000 people, identified an extensive list of associated conditions reaching well beyond the usual suspects. Strong associations emerged not just for autoimmune diseases like connective tissue disorders and Crohn’s disease, but for seemingly unrelated conditions including fibromyalgia, chronic fatigue syndrome, depression, sleep apnea, irritable bowel syndrome, and rosacea.¹³ That breadth suggests dry eye is often a systemic problem with local symptoms rather than a purely local eye condition.

Medications That Dry the Eyes

A wide range of commonly prescribed drugs can contribute to dry eye, and the effects are likely additive when someone is taking several at once. Antihistamines, antidepressants, beta-blockers, diuretics, and oral contraceptives all have the potential to reduce tear production or alter tear composition. The eye drops themselves can be part of the problem: long-term use of preserved topical medications, particularly those containing the preservative benzalkonium chloride (BAK), can damage the cells on the eye surface and worsen dryness.¹⁸ This creates an ironic situation for people using preserved artificial tears or glaucoma drops multiple times a day: the treatment can feed the problem. Preservative-free formulations avoid this issue, which is why eye care providers increasingly recommend them for people who need frequent drops.

Environmental Exposures

The air around you shapes your dry eye risk in ways that go beyond the obvious “it’s windy.” Both outdoor air pollution and indoor air quality affect the eye surface. Particulate matter, gaseous pollutants, and volatile organic compounds can all trigger or worsen tear film instability and inflammation.¹⁹ Temperature, humidity, wind speed, altitude, and even ultraviolet radiation all play a role.²⁰

Indoor environments get less attention but may matter more for office workers who spend most of their waking hours inside. A study measuring real-time indoor conditions found that both humidity levels and fine particulate matter concentrations were correlated with dry eye symptom severity. Increases in indoor PM2.5 were associated with worse symptom scores, lower tear production, and greater meibomian gland dropout.²¹ This has practical implications: air filtration, humidifiers, and positioning your workspace away from direct HVAC vents can make a measurable difference. The Dutch Lifelines study also flagged nitrogen dioxide, a common urban air pollutant, as an independent risk factor for dry eye.¹³

The Omega-3 Debate

Omega-3 fatty acid supplements are one of the most frequently recommended complementary treatments for dry eye, but the evidence is genuinely mixed. Multiple meta-analyses of randomized trials have concluded that omega-3 supplementation improves dry eye symptoms and certain clinical signs like tear break-up time and tear production.²² The proposed mechanism involves both anti-inflammatory effects and changes to the lipid composition of meibomian gland secretions.²³

However, the largest single trial on the topic, the DREAM study published in the New England Journal of Medicine, found no significant difference between omega-3 supplements and an olive oil placebo on any of its primary outcome measures, including corneal staining, tear break-up time, and Schirmer test values.²⁴ One complicating factor is that the olive oil placebo itself may have anti-inflammatory properties, potentially masking a real difference. The overall picture suggests omega-3s may offer modest benefits for some people, but they are not the reliable fix they are often marketed as.

Depression, Anxiety, and Chronic Pain

The relationship between dry eye and mental health runs deeper than “feeling frustrated about dry eyes.” A meta-analysis found that dry eye symptom scores were significantly associated with both depression and anxiety, with moderate effect sizes for each.²⁵ A large population-based study put numbers on the association: people with dry eye had roughly three times the odds of having anxiety or depression compared with people without it.²⁶ The relationship appears bidirectional. Depression and anxiety may increase pain perception and reduce tolerance for discomfort, amplifying dry eye symptoms. At the same time, chronic eye discomfort that interferes with reading, working, and driving can erode quality of life enough to trigger or worsen mood disorders.

The connection extends into the realm of neuropathic pain. In some chronic dry eye patients, the corneal nerves themselves become sensitized, firing pain signals even when the eye surface looks relatively normal. Research suggests this involves both peripheral and central sensitization processes, the same kinds of pain-pathway changes seen in conditions like fibromyalgia and chronic regional pain syndromes.²⁷ This helps explain why some patients respond poorly to conventional dry eye treatments aimed at improving the tear film. If the nerves are the problem, lubricating the surface may not be enough.

The Financial Weight of Dry Eye

Dry eye is often perceived as a nuisance rather than a serious condition, but its economic impact says otherwise. A U.S. decision-tree analysis estimated the average annual cost of managing a patient with dry eye at about $780 from the healthcare payer’s perspective, which scaled to roughly $3.8 billion for the U.S. healthcare system. When indirect costs like lost work productivity were included, the societal cost ballooned to about $11,300 per patient per year.²⁸ A Canadian study painted an even starker picture, finding that the majority of costs were driven by “presenteeism,” the productivity loss from being at work but unable to function at full capacity because of symptoms. Total annual costs per patient averaged about C$24,000 when presenteeism was included, and costs for severe cases were more than four times higher than for mild cases.²⁹ Those numbers make dry eye comparable in economic impact to many chronic conditions that get significantly more public attention.

Sleep and the Overnight Tear Film

Your tear film behaves differently while you sleep. When the eyes are closed, the surface enters a low-oxygen state, tear secretion drops, and the chemical makeup of tears shifts. pH, osmolarity, and inflammatory markers all change between the daytime open-eye state and the closed-eye overnight state.³⁰ Research has found that both healthy and dry-eyed patients wake up with higher tear volumes than they had before bed, and dry eye patients specifically show improved tear film stability right after waking.³¹ That overnight “recharge” effect may explain why many people with dry eye feel best in the morning and worst in the late afternoon or evening.

Sleep disorders complicate this picture. Poor sleep quality and insufficient sleep duration are both associated with increased dry eye symptoms, possibly because disrupted sleep does not allow the tear film to fully recover. The Dutch Lifelines study identified sleep apnea as an independent risk factor for dry eye.¹³ Incomplete eyelid closure during sleep, common in people who use CPAP machines or who have natural lid laxity, can also expose the cornea to air overnight and worsen surface drying.

The Eye’s Microbiome

The eye surface, like the gut and skin, harbors a community of microorganisms. Research into the ocular surface microbiome and dry eye is still in its early stages, but recent work has identified specific bacterial species that appear to mediate improvement in meibomian gland function. Species such as Staphylococcus epidermidis and others were found to suppress inflammation-associated bacteria and support healthier ocular surface conditions.³² The idea that shifting the balance of eye-surface bacteria could treat dry eye is still speculative, but it opens up a genuinely different line of thinking from the tear-supplement and anti-inflammatory approaches that dominate current treatment. Microbiome-targeted therapies for dry eye are years away from clinical use, but the concept that your eye flora matters for tear film health is gaining traction.

1
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PubMed. Structural and functional changes in corneal innervation after laser in situ keratomileusis and their relationship with dry eye
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PubMed Central. Sjögren’s Syndrome: More Than Just Dry Eye
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PubMed Central. Systemic Conditions Associated with Severity of Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management Study
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PubMed Central. Rheumatoid Arthritis Associated with Dry Eye Disease and Corneal Surface Damage: A Nationwide Matched Cohort Study
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PubMed Central. Environmental Drivers of Dry Eye Disease: A Narrative Review of Pollutants, Climate, and Indoor Exposures with Practice Recommendations
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JAMA Ophthalmology. Association of the Indoor Environment With Dry Eye Metrics
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