Dry Eye Alertness: Reading Between the Lines (Before the Exam Even Starts)

By Chris Wolfe, OD, FAAO, Dipl. ABO

Most of the time, we already know a patient has dry eye disease before we even sit down. It’s not guesswork—it’s experience. When we’ve seen enough of it, the patterns become clear. The clues are in the intake forms, the medication lists, the patient’s age, the environment they work in. The real challenge isn’t diagnosing dry eye—it’s catching it early enough that we can manage it before it becomes chronic and frustrating.

Women over the age of 40 are often the clearest example. If we’re not assuming some level of ocular surface disease in this population, we’re probably underdiagnosing it. Hormonal changes reduce tear production and destabilize meibomian gland function. If they’re wearing contacts, spending long hours in front of a screen, or taking systemic medications that impact tear film, then they’re at a higher risk—even if they don’t report symptoms yet.

Refractive surgery history is another red flag we should be tuned into. A lot of these patients didn’t choose LASIK or PRK because they hated glasses. They chose it because they became intolerant to their contact lenses. And they became intolerant not because the lenses were bad—but because they already had meibomian gland dysfunction and dry eye. The contact lenses just made it obvious sooner. So they get the surgery and think the problem is fixed. But the underlying dry eye was never addressed. Fast forward 10 or 15 years, and now they’re symptomatic again—burning, gritty, and wondering why. The answer is: the disease was always there. We just didn’t catch it early enough.

We should be using that surgical history as a breadcrumb trail. It’s it’s a chance to dig deeper, ask the right questions, and identify who needs our attention before the disease advances further.

The same goes for contact lens wearers in general. One of the most telling questions we can ask is, “Do your eyes itch when you take your contacts out?” If the answer is yes, we don’t need osmolarity testing or an MMP-9 to raise concern. That patient is already on the path to dry eye, even if they only feel it at the end of the day.

Heavy screen users are another growing group we have to stay ahead of. Blinking is reduced, the air is dry, and most of these environments don’t support ocular surface health. If a patient is clocking 8+ hours a day in front of a screen, even with no symptoms, we should still be thinking about tear film stability and meibomian gland function. Because once the symptoms show up, the damage has already started.

Medication history can be just as revealing. Isotretinoin (Accutane) is notorious for wrecking the glands. Dupixent may help with skin but often comes with dry eye baggage. SSRIs like Lexapro, Prozac, and Zoloft reduce tear production. Antihistamines dry out more than just sinuses. Hormone therapy, thyroid disease, lupus, RA, these are not background details. These are front-line factors in dry eye development. And they’re telling us that we need to look more closely, even if the patient isn’t in pain yet.

What all of this adds up to is a shift in mindset. We have to stop thinking of dry eye as something we confirm with a stain and treat with a sample. This is chronic disease. It needs to be diagnosed early, tracked over time, and managed like any other condition we take seriously.

When we treat dry eye as a core part of our medical eye care—when we see it not as an inconvenience but as a clinical pillar—we help patients stay comfortable, stay functional, and stay with us long-term. That’s good care. And frankly, it’s good business.

So when we walk into the room and meet a 47-year-old woman on Lexapro and Allegra, working full time on screens, wearing monthly lenses, with a history of LASIK, who says her eyes feel dry or burn by the end of the day—we shouldn’t wait. That’s not a subtle case. That’s dry eye. And it’s up to us to recognize it, treat it, and keep it from getting worse.