A Sex-Specific Look at Dry Eye
AT A GLANCE
- In the United States, an estimated 3.2 million women and 1.68 million men who are 50 years of age or older have dry eye disease.
- Sex-specific changes in the cornea occur during menstruation, pregnancy, and menopause.
- Changes to the eye that occur during pregnancy are temporary and usually resolve after giving birth.
Dry eye disease (DED) is a growing issue with our patients, and the problem is especially prevalent in women. In the United States, an estimated 3.2 million women and 1.68 million men who are 50 years of age or older have DED.1,2 This article examines the various causes of DED in women in an effort to facilitate earlier diagnosis and thus improve patient outcomes.
THE FEMALE EYE
Studies have shown that women between 40 and 49 years of age3 and those who are pregnant4 are at increased risk of developing DED. Many factors can cause DED (see Dry Eye Risk Factors), but physiologic differences may contribute to the different DED prevalence rates observed in women and men. For example, sex-specific changes in the cornea occur during menstruation, pregnancy, and menopause, and they include variations in thickness, hydration, curvature, sensitivity, and endothelial pigmentation as well as contact lens tolerance and decreases in visual acuity.
Pregnancy and the Eye
Changes to the eye that occur during pregnancy are temporary and usually resolve after giving birth.5 These changes include alterations in refraction that cause a myopic shift or even a temporary loss of accommodation,4 decrease in corneal sensitivity,4 and reduction in contact lens tolerance.6 Refractive surgery is therefore contraindicated during pregnancy, and new eyeglass and contact lens prescriptions should be postponed until several months after delivery.7
Pregnancy can also affect tear film physiology and lead to DED, which may be attributed to an increased immune reaction in the lacrimal duct cells and the direct destruction of acinar cells by prolactin, transforming growth factor beta-1, and epidermal growth factor.4 In addition, newly developed Krukenberg spindles, not accompanied by other findings of pigment dispersion, have been observed early in pregnancy, although these usually decrease during the third trimester and disappear completely postpartum.4
Menopause and the Eye
The rate of DED in women who are 50 years of age and older is nearly double that of men of a similar age (7% vs 4%).1 Alterations in sex hormones play an important role in the pathophysiology of DED in perimenopausal and menopausal women.8 In menopause-related DED, it is unclear if hormone replacement therapy increases, decreases, or does not affect the risk of DED, because various studies have found all three scenarios to be true.9-11
TREATMENT OPTIONS
As with many ocular conditions, left untreated, DED can become chronic and progressive, and it can significantly affect a patient’s quality of life. The management of DED is the same in men and women. Options include artificial tears and ointments, punctal plugs, a modified diet, an evaluation of medications, treatment of associated medical issues, delayed contact lens refitting, an evaluation of the patient’s makeup use, and reduced time on digital devices.
READ THE ROOM
The prevalence of DED is increasing, especially as people’s screen time rises during the COVID-19 pandemic. If a pregnant patient or a woman who is 40 years of age or older complains that her eyes feel like they are burning or stinging, that her eyes are red, or that her vision is blurry, DED is a likely diagnosis based on the statistics.
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