A challenge with older DED patients isn’t detecting the disease – that reveals itself in the exam, regardless of age – but rather in how to approach DED in the context of a more complex picture of overall health. The underlying issues are often more nuanced. A comprehensive DED plan depends on understanding the patient’s health history, the underlying cause of their DED, and the practical realities involved, from insurance constraints to manual dexterity.
Holistic health
When I review the overall health of my older patients, the first step is a thorough medical history. I want to confirm any existing conditions, such as diabetes, rosacea, or autoimmune diseases, and note whether anything has changed or been added since their last visit. Medication lists also evolve, and those updates can directly influence the ocular surface. Alongside this, normal age-related changes in the eyelids can affect lid position and function. With that context in mind, here’s what I assess before planning therapy:
Systemic conditions – Advancing age increases the prevalence of many systemic conditions, including some that can significantly affect the ocular surface. Diabetes affects corneal nerve function, decreasing sensation and activation of the lacrimal functional unit, and potentially reducing innervation of the lacrimal gland (3).
Medications – Needing a larger pill sorter goes hand-in-hand with aging, and several medications can shape the DED picture. Systemic medications, including antihypertensives, antihistamines, antidepressants, and anticholinergics, are well-known contributors. Long-term antibiotics can disrupt the gut microbiome and affect the gut–eye axis; history or ongoing use of chemotherapy agents have substantial ocular surface effects (5); and don’t forget about preserved glaucoma drops, which often make DED worse. Re-evaluating these therapies is essential when building an effective plan.
Eyelid and ocular tissue changes – Aging-related changes within the periocular region can affect eyelid positioning, as well as changes to the eyelids themselves. For example, as aging skin loses elasticity, collagen, and subcutaneous fat, the cheeks shift downward, which can, in turn, pull down the lower eyelids. Dermatochalasis and conjunctivochalasis can affect lid closure as well. Risks for floppy eyelid syndrome and sleep apnea also increase. These changes in eyelid positioning can increase incomplete blinking, nocturnal lagophthalmos, and subsequent exposure keratitis. Conjunctivochalasis is another change that can occur with age, leading to blink discomfort, tearing, and goblet cell loss seen with lissamine green staining.
Hormone changes – Hormones influence DED at all ages. The condition is more common in women, particularly postmenopausal, but age-related hormonal changes in men also play a significant role (6). Hormonal changes also affect skin pH, which can increase the bacterial growth and demodex proliferation, and worsen rosacea (7,8).
Management tips
Medications and insurance coverage– Every patient’s financial situation is different. Still, I factor in cost because Medicare Part D and supplemental coverage can be inconsistent, co-pays may be high, and patients typically aren’t eligible for manufacturer coupons. As a result, it can be challenging to get approval for some medications, especially newer medications which may not be on formulary yet. When my patients have dexterity issues that make it hard to utilize single-use vials, I may prescribe Tyrvaya (Viatris) nasal spray or a multidose bottle of Restasis (AbbVie) or Vevye (Harrow).
Over-the-counter therapies– At checkout, my patients receive an individualized printed protocol for their treatments, including over-the-counter therapies. It includes a treatment grid that lists when and how often to do treatments, as well as written instructions on how to perform lid hygiene and warm compresses and where they can obtain all OTC products. When it comes to products, pictures make it easier to identify which ones I am recommending. For example, I recommend that patients use iVIZIA (Thea), a preservative-free artificial tear in a multi-dose bottle, and The Daily Lid Wipe (myze), a preservative-free tea tree oil eyelid wipe.
Eyelid changes – Oculoplastics and aesthetics referrals are a discussion with older patients to improve lid positioning, incomplete blink, dermatochalasis, and conjunctivochalasis. I treat a lot of lagophthalmos in older patients, using Optase Hylo Night (Scope) vitamin A ointment, goggles, or Sleeptite/SleepRite adhesive patches (Ophthalmic Resources Partners), which are gentle enough for older skin.
References
- MW Sahli et al., “Findings from Optometrists’ Practices in Advising about Lifestyle Study,” Optom Vis Sci, 97, 598 (2020). PMID: 32833404. A Sharma, HB Hindman, “Aging: a predisposition to dry eyes,” J Ophthalmol, 2014, 781683 (2014). PMID: 25197560.
- S Priyadarsini et al., “Diabetic keratopathy: insights and challenges,” Surv Ophthalmol, 65, 513 (2020). PMID: 32092364.
- A Leonardi et al., “Dry eye and systemic diseases,” Saudi J Ophthalmol, 39, 5 (2025). PMID: 40182960.
- EA Stoicescu et al., “Ocular adverse effects of anti-cancer chemotherapy,” J Med Life, 16, 818 (2023). PMID: 37675170.
- DA Sullivan et al., “TFOS DEWS II Sex, Gender, and Hormones Report,” Ocul Surf, 15, 284 (2017). PMID: 28736336.
- Z Wang et al., “Aging-associated alterations in epidermal function and their clinical significance,” Aging (Albany NY), 12, 5551 (2020). PMID: 32217811.
- A Asees et al., “The skin microbiome in rosacea: mechanisms, gut-skin interactions, and therapeutic implications,” Cutis, 116, 20 (2025). PMID: 40875939.
