Ocular Symptom Severity in Dry Eye Disease Associated with Sleep Quality

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Eyes with DED showed a correlation between the severity of ocular symptoms, obtained using dry eye and pain questionnaires, and all aspects of sleep quality.

A new cross-sectional analysis examined how specific components of sleep quality and other components identified in ocular examinations related to symptoms of dry eye disease (DED) to highlight holistic approaches to dry eye management.1

Among individuals who completed sleep questionnaires, and underwent ocular examinations, the analysis showed sleep disturbances were significantly associated with most DED symptoms and ocular pain metrics, while ocular surface inflammation and meibum quality remained significantly associated with subjective sleep quality.

“This study adds a unique perspective on the relationship between DED and sleep by examining how specific components of sleep relate to DED symptoms and ocular exam findings,” wrote the investigative team, led by Anat Galor, MD, of the University of Miami Health System Bascom Palmer Eye Institute.

Quality of life can be severely impacted by DED symptoms, with impacts ranging from work productivity to physical well-being and mental health, leading to a significant burden on the larger population.2 Evidence has suggested DED is associated with significantly poorer sleep quality, including less time asleep and more sleep disturbances compared with controls. Across multiple studies, symptoms of sleep quality have been linked to an increased risk of reporting DED symptoms, while signs of DED show less of an association with sleep.

To further examine the connection between DED and sleep disturbances, Galor and colleagues analyzed the association between ocular surface symptoms (pain and non-pain-related) and signs with various aspects of sleep quality.1 The team noted this understanding could benefit the development of specific interventions for individual sleep quality and improve the quality of life for patients.

The cross-sectional study included veterans who were seen in an eye clinic at the Miami Veterans Affairs Medical Center between November 2018 and July 2023. Each study participant filled out questionnaires to measure the severity of DED symptoms, using the 5-Item Dry Eye Questionnaire (DEQ-5) (range, 0 – 22) and Ocular Surface Disease Index (OSDI) (range, 0 – 100) questionnaires. Each questionnaire measures different symptom aspects, including pain, visual disturbances, and other aspects of the disease.

To examine relationships been ocular pain and sleep, investigators used the Numerical Rating Scale (NRS) (range, 0 – 10) and Neuropathic Pain Symptom Inventory modified for the Eye (NPSI-E) (range, 0 – 100). Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI), including 19 individual items for a total of 7 component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.

A total of 141 individuals (mean age, 56 years) were included in the study, with the majority (76%) reporting mild or greater DED symptoms (DEQ-5 score ≥6). Galor and colleagues indicated mental health and fatigue scores were higher among those with DED symptoms, as were all ocular symptom scores, including those pain specific. Sleep quality scores were also higher in those with DED symptoms, save for the use of sleeping medications.

Overall, investigators found ocular symptoms were more closely related to sleep metrics than sleep signs. Analyses showed the strongest association for DED symptoms was between OSDI and sleep disturbances (PSQI subscore 5: r = .49; P <.0005). The association between DED signs and sleep metrics was less strong, however, as ocular surface inflammation and meibum quality related to subjective sleep quality (PSQI subscore 1: r = .29; P = .03 for both).

Linear regression analyses revealed sleep disturbances remained significantly associated with most DED symptoms and ocular pain metrics, including the DEQ-5 (r = .36; P <.0005), OSDI (r = .31; P <.0005), and NRS (r = .52; P <.0005). Investigators indicated that ocular surface inflammation (r = .26; P = .01) and meibum quality (r = .46; P <.0005) also remained significantly associated with subjective sleep quality.

“To conclude, we found that ocular symptom severity, captured both with DED and pain questionnaires, was related to all components of sleep quality, except for the use of sleep medication,” Galor and colleagues wrote.


  1. Ayoubi M, Cabrera K, Mangwani S, et alAssociations between dry eye disease and sleep quality: a cross-sectional analysisBMJ Open Ophthalmology 2024;9:e001584. doi: 10.1136/bmjophth-2023-001584
  2. 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