Clinical Report: Rethinking Dry Eye Symptoms and Their Masqueraders
Overview
Persistent ocular discomfort is not always due to dry eye disease. Conditions such as ocular allergies, conjunctivochalasis, corneal pathologies, and corneal nerve dysfunction can mimic dry eye symptoms and require distinct diagnostic and therapeutic approaches.
Background
Dry eye disease is a common cause of ocular discomfort characterized by symptoms like burning, itching, and fluctuating vision. However, several other ocular conditions can present with similar symptoms, leading to misdiagnosis and ineffective treatment. Recognizing these dry eye masqueraders is essential for appropriate management. The 2025 American Academy of Optometry meeting highlighted these conditions and their tailored treatment strategies.
Data Highlights
| Condition | Key Symptoms | Diagnostic Clues | Treatment Approaches |
|---|---|---|---|
| Ocular Allergy | Itching, burning, fluctuating vision | Inflammation, meibomian gland changes | Antihistamine–mast cell stabilizers, allergen avoidance, topical cyclosporine |
| Conjunctivochalasis | Epiphora, fluctuating vision, foreign-body sensation | Disrupted tear flow | Non-surgical options, excision, tissue-shrinking procedures |
| Corneal Pathologies | Dryness, glare, fluctuating vision | Epithelial basement membrane dystrophy, Salzmann nodular degeneration | Lubrication, keratectomy |
| Corneal Nerve Dysfunction | Pain without stain, stain without pain | Mismatched signs and symptoms | Amniotic membranes, biologic-derived drops, neuromodulators |
| Eyelid Anomalies | Incomplete eyelid closure, dry eye symptoms | Entropion, ectropion, floppy eyelid syndrome | Ointments, sleep masks, eyelid tape, surgery |
Key Findings
- Ocular allergy is a frequent dry eye masquerader presenting with itching, burning, and fluctuating vision, often requiring antihistamines and allergen avoidance.
- Conjunctivochalasis disrupts tear flow causing symptoms similar to dry eye and may need surgical intervention in advanced cases.
- Corneal pathologies like epithelial basement membrane dystrophy can mimic dry eye symptoms and may require keratectomy.
- Corneal nerve dysfunction presents with a mismatch of signs and symptoms and benefits from nerve-targeted therapies.
- Eyelid anomalies such as entropion and floppy eyelid syndrome contribute to dry eye symptoms and may need both conservative and surgical treatments.
- When dry eye treatments fail, clinicians should investigate alternative diagnoses to improve patient outcomes.
Clinical Implications
Clinicians should maintain a high index of suspicion for dry eye masqueraders when patients do not respond to standard dry eye therapies. Comprehensive evaluation including staining of both conjunctiva and cornea and assessment of eyelid anatomy is critical. Tailored treatments targeting the underlying masquerading condition can significantly improve patient satisfaction and symptom relief.
Conclusion
Dry eye symptoms can arise from a variety of ocular conditions beyond classic dry eye disease. Identifying and treating these masqueraders is essential for effective management and improved patient outcomes.
References
- Ioussifova et al. 2025 -- Dry Eye Masqueraders: What To Do When Dry Eye Treatments Don’t Work
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