Our bodies, including our eyes, repair and restore themselves while we sleep. Our eyes specifically need to be coated in moisture to repair properly, which means our patients who do not routinely get the necessary 7 to 9 hours of rest are at risk of not only developing dry eye disease (DED), but also having that DED worsen over time. 

The Tear Film and Ocular Surface (TFOS) Lifestyle Workshop’s section on sleep indicates that both quality and quantity of sleep have a correlation to DED.¹ Namely, our dry eye patients suffer a reduction in their quality of life when worsening DED limits both their work and social lives. Subjective sleep quality, latency, duration, and efficiency all influence the development, severity, and frequency of DED symptoms across ages and genders.^2-3 Studies have also found that the sleep/DED relationship is bidirectional: Patients with DED have lower sleep quality,⁴ and those with low sleep quality have a higher prevalence of DED.⁵ 

Two systems are thought to cause the increase of dry eye symptoms in our patients with poor sleep—hormones and the autonomic nervous system:

• Poor sleep reduces androgen levels, alters circadian rhythms, and increases the release of stress hormones.² Lowered androgen levels and altered circadian rhythms have been found to affect both lacrimal and meibomian gland functions.⁶ 

• A reduction in sleep hours results in decreased parasympathetic activity, which leads to reduced tear production. Less sleep also causes greater tear film instability and increases tear evaporation.⁷

Therefore, helping these patients improve their sleep quantity and quality can go a long way toward helping them to restore their healthy eyes.

How Do We Identify These Patients?

Simply start a conversation with your patients about the quality of their sleep. You can ask simple questions such as:

• How many hours do you sleep in an average night?

• How often do you wake up in the middle of the night?

• Has anyone ever told you that you snore loudly?

If you’d like to dive deeper or get a true assessment of your patient’s quality of sleep, consider giving them the Pittsburg Sleep Quality Index (PSQI).⁸ 

The Fix

The tears that are secreted while the eye is closed have immunosuppressive properties, such as increased secretory IgA, neutrophil activity, and complement activation,³ which shift the ocular surface into a state of repair and defense. For patients with severe sleep disorders, a referral to their primary care physician or a sleep specialist is in order to mitigate impediments to the ocular surface repair process.

You can also help your patients develop better sleep hygiene with some tips:

1. Set a consistent bedtime schedule

2. Eliminate sources of blue light (ie, cell phones, computers, tablets, and televisions) 1 hour before bedtime

3. Avoid caffeine in the afternoons or set a caffeine curfew

4. Consider a sleep-enhancing supplement (melatonin, magnesium, or valerian root)

5. Take a warm bath or shower before bed and lower the thermostat to 65° to 68° F

Conclusion

When we think about our highly symptomatic dry eye patients, we should keep in mind that 1 in 2 are also poor sleepers.¹ Improving their quality of sleep over time with a few simple daily habits may help their eyes feel less gritty and inflamed during the day, and could truly make a substantial impact on their quality of life, especially for those with frequent symptoms.² OM

References

1. Galor A, Britten-Jones AC, Feng Y, et al. TFOS lifestyle: impact of lifestyle challenges on the ocular surface. Ocul Surf. 2023;28:262-303. doi:10.1016/j.jtos.2023.04.008
2. Magno MS, Utheim TP, Snieder H, Hammond CJ, Vehof J. The relationship between dry eye and sleep quality. Ocul Surf. 2021;20:13-19. doi:10.1016/j.jtos.2020.12.009
3. Li A, Zhang X, Guo Y, et al. The association between dry eye and sleep disorders: the evidence and possible mechanisms. Nat Sci Sleep. 2022;14:2203-2212. doi:10.2147/NSS.S378751
4. Wu M, Liu X, Han J, Shao T, Wang Y. Association between sleep quality, mood status, and ocular surface characteristics in patients with dry eye disease. Cornea. 2019;38(3):311-317. doi:10.1097/ICO.0000000000001854
5. Karaca EE, Akçam HT, Uzun F, Özdek S, Çiftçi TU. Evaluation of ocular surface health in patients with obstructive sleep apnea syndrome. Turk J Ophthalmol. 2026;46(3):104-108. doi:10.4274/tjo.57778
6. Vu CH, Kawashima M, Nakamura W, Nakamura TJ, Tsubota K. Circadian clock regulates tear secretion in the lacrimal gland. Exp Eye Res. 2021;206;108524. doi:10.1016/j.exer.2021.108524
7. Kim H, Jung HR, Kim JB, Kim DJ. Autonomic dysfunction in sleep disorders: from neurobiological basis to potential therapeutic approaches. J Clin Neurol. 2022;18(2):140-151. doi:10.3988/jcn.2022
8. Buysse DJ, Reynolds CF III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193-213. doi:10.1016/0165-1781(89)90047-4

Pamela E. Theriot, OD is the clinical director of the Dry Eye Relief Center at Williamson-Azar Eye Clinic, a multispecialty practice in Lafayette, Louisiana. In 2021, she was appointed to the public awareness committee of the Tear Film and Ocular Surface Society. In January 2025, she gave a TEDx Talk titled “Seeing Clearly in a Screen-Filled World: 3 Tips to Preserve Your Vision.”