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Sex-related differences and hormonal effects in the Dry Eye Assessment and Management (DREAM) study
  1. Megan Zhao1,2,
  2. Yinxi Yu1,2,3,
  3. Neeta S Roy4,
  4. Gui-shuang Ying1,2,3,
  5. Penny Asbell5,
  6. Vatinee Y Bunya1,2
  1. 1 Penn Medicine, Philadelphia, Pennsylvania, USA
  2. 2 Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3 Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  4. 4 Ophthalmology, Weill Cornell Medicine, New York, New York, USA
  5. 5 Ophthalmology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
  1. Correspondence to Megan Zhao, Penn Medicine, Philadelphia 19104, Pennsylvania, USA; megan.zhao{at}


Background/aims To compare dry eye disease (DED) signs and symptoms between men and women, as well as between premenopausal and postmenopausal women, in the Dry Eye Assessment and Management (DREAM) study.

Methods 434 women and 101 men self-reported prior medical history and underwent a standardised DED assessment using the Ocular Surface Disease Index, Brief Pain Inventory, Tear Break-Up Time (TBUT)(s), Schirmer’s test 2 (mm/5 min), National Eye Institute-graded lissamine conjunctival staining, corneal staining, meibomian gland dysfunction evaluation and tear osmolarity (mOsms/L) at baseline, 6 months and 12 months. Multivariable linear regression models were used to compare these scores.

Results Women experienced significantly worse DED signs than men with lower Schirmer’s test scores (9.27 vs 12.16; p<0.001), higher corneal staining scores (3.59 vs 2.70; p=0.006) and worse composite DED sign scores (0.52 vs 0.40; p<0.001). Postmenopausal women experienced significantly worse DED signs than premenopausal women with higher corneal staining scores (3.74 vs 2.58, p<0.001), higher conjunctival staining scores (2.80 vs 2.22, p<0.001), higher tear osmolarity (304 vs 299, p=0.004), lower TBUT (3.37 vs 3.93, p=0.047), worse meibomian gland dysfunction (3.05 vs 2.62, p=0.04) and worse composite DED sign scores (0.54 vs 0.42, p<0.001). There were no significant differences in DED symptoms between sex and between premenopausal and postmenopausal women (all p≥0.08).

Conclusion In the DREAM study, women experienced more severe DED signs than men. Further, postmenopausal women presented with more severe DED signs than premenopausal women. Elucidating these differences may improve DED diagnosis and provide future direction in understanding sex-related differences in DED.

Trial registration number NCT02128763.

  • Clinical Trial
  • Cornea

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors YY and GSY conducted the data analysis and wrote the methods. MZ and VB wrote the manuscript. MZ, YY, NSR, VB, GSY, and PA conceptualized and edited the manuscript. GSY is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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