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Epidemiology of discordance between symptoms and signs of dry eye
  1. Erin S Ong1,2,
  2. Elizabeth R Felix1,3,
  3. Roy C Levitt1,4,5,6,
  4. William J Feuer2,
  5. Constantine D Sarantopoulos1,4,
  6. Anat Galor1,2
  1. 1 Miami Veterans Administration Medical Center, Miami, Florida, USA
  2. 2 Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA
  3. 3 Department of Physical Medicine and Rehabilitation, Miller School of Medicine, University of Miami, Miami, Florida, USA
  4. 4 Department of Anesthesiology, Miller School of Medicine, Perioperative Medicine and Pain Management, University of Miami, Miami, Florida, USA
  5. 5 School of Medicine, John P. Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA
  6. 6 John T. Macdonald Foundation Department of Human Genetics, Miller School of Medicine, University of Miami, Miami, Florida, USA
  1. Correspondence to Dr Anat Galor, Department of Ophthalmology, Miami VA Medical Center, Miami, Florida 33125, USA; agalor{at}


Background/aims The frequent lack of association between dry eye (DE) symptoms and signs leads to challenges in diagnosing and assessing the disease.

Methods Participants underwent ocular surface examinations to evaluate signs of disease and completed questionnaires to assess ocular symptoms, psychological status and medication use. To assess nociceptive system integrity, quantitative sensory testing (QST), including vibratory and thermal threshold measures and temporal summation of pain were obtained at the forearm and forehead. Correlations between DE discordance score (degree of discrepancy between symptom severity and DE signs) and patient characteristics were determined. Higher discordance scores indicated more symptoms than signs.

Results 326 patients participated (mean age: 62 years; SD: 10 years; 92% men). Age was negatively correlated with DE discordance score (Pearson r=−0.30, p<0.0005), while mental health indices were positively correlated. Chronic pain elsewhere in the body (ie, non-ocular pain conditions) and intensity ratings of prolonged aftersensations of pain evoked by noxious hot and cold stimuli were also significantly correlated with DE discordance score. Multiple linear regression demonstrated that post-traumatic stress disorder and non-ocular pain intensity were important predictors of DE discordance score, Dry Eye Questionnaire-5 and Ocular Surface Disease Index and that DE discordance was also sensitive to QST as well.

Conclusions The present study provides evidence that the degree of discordance between DE symptom report and measurable signs of ocular surface disease is associated with comorbidities related to clinical pain and to hyperalgesia as demonstrated with QST. Understanding the epidemiology of DE discordance can aid in interpreting the DE exam and individualising treatment.

  • dry eye
  • signs symptoms discordance
  • quantitative sensory testing
  • central sensitization

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  • Contributors All authors contributed to the design and execution of this work, and all approved of this regarding submission.

  • Funding Supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research EPID-006-15S (Dr AG), NIH Center Core Grant P30EY014801 and Research to Prevent Blindness Unrestricted Grant. The above sponsors provided financial support to cover the researchers' time but were not involved in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; or decision to submit the manuscript for publication. We would like to note that the contents of this study do not represent the views of the Department of Veterans Affairs or the United States Government.

  • Competing interests None declared.

  • Patient consent All patients signed Miami VAMC informed consent form.

  • Ethics approval Miami Veterans Administration Medical Center (VAMC) Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement AG had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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