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Which Medications Can Cause Dry Eye?
Dry eye, a chronic condition that occurs when your eyes don’t have adequate lubrication, stems from a variety of causes: eye disease, autoimmune illness, allergies, hormonal changes, vitamin A deficiency, and — you may be surprised to learn — drug interactions.
Various prescription and over-the-counter medications can increase the risk of developing dry eye syndrome, either by directly affecting the eyes or by causing other physical changes that indirectly impact the eyes.
If you’re experiencing dry eye, learning that a medication is the culprit can be a first step toward getting relief from stinging, redness, pain, light sensitivity, and other symptoms.
Antihistamines reduce the amount of histamine (a type of chemical messenger) produced by your immune system. They relieve allergy symptoms but also dry out the “tear film” — the mix of oils, watery fluid, and mucus that coat the eye’s surface.
Antihistamines cause dry eye by changing the composition and production of tears in two ways:
- By blocking receptors that regulate fluid secretion in the eye
- By blocking nerve signals needed to produce the right amounts of water and oil, resulting in fewer tears and a poor quality tear film
Examples of antihistamines that can cause dry eye include:
- Diphenhydramine (Benadryl)
- Loratadine (Claritin)
- Cetirizine (Zyrtec)
- Fexofenadine (Allegra)
Some eye drops contain preservatives. These can, paradoxically, cause dry eye and possibly damage the eye’s surface.
Some research suggests the preservative benzalkonium chloride may cause dry eye by preventing cells in the cornea (the clear outer layer at the front of the eye) from working properly, although more studies are needed.
The authors of a 2023 study recommended using preservative-free eye drops to manage dry eye.
Using eye drops incorrectly — for instance, applying two or more types too close together — may also increase dry eye risk. If your doctor prescribes eye drops, be sure to follow the instructions carefully.
Decongestants such as pseudoephedrine (Sudafed) aim to reduce mucus, but these drugs also hinder the so-called mucin layer that holds the tear film to the eye’s surface. Decongestants can also affect the water component of the tear film.
In addition, decongestants work on the nervous system to reduce the size of blood vessels in the sinuses. This affects blood flow and ultimately leads to reduced tear production and, potentially, dry eye.
Animal research suggests regular decongestant use may lead to long-term damage to eye tissue.
Different types of antidepressants can cause dry eye in different ways.
SSRIs
In a 2023 animal study, researchers found evidence that selective serotonin reuptake inhibitors (SSRIs) may cause eye damage from dry eye by raising serotonin levels in tears. Serotonin is a chemical messenger in the brain implicated in some forms of depression.
Among other theories are that SSRIs increase the risk of eye inflammation or affect tear production and tear film stability.
Examples of SSRIs include:
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
SNRIs
Serotonin-norepinephrine reuptake inhibitors (SNRIs) seem less likely than SSRIs to cause dry eye, but more research is needed to understand the link between dry eye and SSRIs or SNRIs.
Examples of SNRIs include:
- Venlafaxine (Effexor)
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
Tricyclic Antidepressants
Antidepressants such as amitriptyline (Elavil) increase levels of the chemicals messengers serotonin and norepinephrine in your brain. They help regulate mood but can also block signals to the tear-producing lacrimal glands, reducing tear production.
Beta-blockers reduce the activity of beta receptors, which play a key role in various bodily functions. They can make you feel more relaxed, but they can also cause dry eye.
One reason may be that beta-blockers reduce the levels of lysozyme, an immune-system enzyme, and immunoglobulin A, also part of the immune defense, which protects mucous membranes.
Beta-blockers may also affect tear production by reducing the cornea’s sensitivity.
A variety of medications used to treat cardiovascular issues can lead to dry eye.
Beta-Blockers for Hypertension
Some doctors prescribe beta-blockers for high blood pressure. People taking beta-blockers for this reason may be at risk of dry eye.
Examples of beta-blockers for hypertension include:
- Carvedilol (Coreg)
- Labetalol (Trandate)
- Nebivolol (Bystolic)
Diuretics
Diuretics are also known as water pills. Examples include furosemide (Lasix) and hydrochlorothiazide (Microzide).
Diuretics manage blood pressure by reducing fluid levels in the body. However, less fluid can mean fewer tears and a higher chance of dry eye.
Statins
Statins lower cholesterol and help prevent blood clots. However, some research suggests statin use may result in a deterioration of the eyelid’s oil-producing (meibomian) gland and the quality of meibum in the tear film, resulting in dry eye.
Examples of statins include:
- Atorvastatin (Lipitor)
- Rosuvastatin (Crestor)
- Simvastatin (Zocor)
Isotretinoin (Accutane) manages acne by reducing oil production in the body. But it also reduces the oil needed for healthy tears, potentially leading to dry eye.
Isotretinoin can also damage the tissues of the meibomian gland, reducing the quality and effectiveness of tears, says Anat Galor, MD, spokesperson for the American Academy of Ophthalmology and cornea specialist at the University of Miami Health System.
These changes are reversible and usually get better after you stop using the drug.
NSAIDs reduce inflammation throughout the body.
With long-term use, however, NSAIDs can reduce corneal sensitivity and may even damage the cornea. These changes can lower tear production, leading to dry eye.
While the exact mechanism is unclear, experts recommend monitoring closely for dry eye when using NSAIDs, especially if you turn to them for eye pain.
Examples of NSAIDs include:
- Ibuprofen (Advil)
- Diclofenac (Voltarol)
- Nepafenac (Nevanac)
Eye problems, including dry eye, are a common symptom of Parkinson’s disease, and some Parkinson’s treatments can cause or worsen dry eye.
Trihexyphenidyl (Artane) can reduce muscle tremors, but it can also cause dryness in the mucous membranes, making dry eye more likely.
A newer Parkinson’s drug, levodopa (Sinemet), works by increasing the activity of the chemical messenger dopamine in the brain. However, levodopa can also increase the risk of dry eye.
PPI inhibitors and H2 blockers can ease digestive discomfort, but they may also lead to dry eye.
PPI Inhibitors
Many people use proton pump inhibitors (PPIs) to treat acid reflux and peptic ulcers, but research suggests a strong link between PPIs and dry eye.
The reason is unclear, but PPIs may affect the absorption of vitamin B12. This could lead to a B12 deficiency, one symptom of which is dry eye.
Examples of PPIs include:
- Esomeprazole (Nexium)
- Lansoprazole (Prevacid)
- Omeprazole (Prilosec)
- Dexlansoprazole (Dexilant)
- Pantoprazole (Protonix)
- Rabeprazole (AcipHex)
H2 Blockers
H2 blockers (histamine-2 receptor antagonists) reduce stomach acid production by blocking histamine.
But, as with other antihistamines, they can also cause dry eye.
Examples include:
- Cimetidine (Tagamet)
- Famotidine (Pepcid)
- Nizatidine (Axid)
The effects of chemotherapy drugs on eye health are complex and depend on the drug.
Consider the following:
- Taxanes This class of chemotherapy drugs, including paclitaxel (Taxol) and docetaxel (Taxotere), disrupts cell division, which may cause issues with the meibomian gland and obstruct the channels through which tears flow.
- S-1 chemo This chemo medication sometimes leads to severe meibomian gland issues, possibly due to toxins from the drug entering tears.
- Aromatase inhibitors Medications like letrozole (Femara) can lower the risk of breast cancer returning after treatment, but may increase the risk of dry eye, possibly due to a lower meibum production. However, more research is needed to confirm this connection.
Scientists have linked changes in various sex steroid hormones to dry eye.
Hormonal Birth Control
One study found that people using hormonal birth control regularly were more likely to have dry eye than those not using it.
The exact reason is unclear, but supplementing with estrogen may suppress the function of the meibomian gland, experts say. It may also reduce the activity of oil-producing glands.
Animal studies have suggested that estrogen therapy may affect genetic and molecular processes involved in the glands responsible for the production of tears (lacrimal glands) and tear-film oil (meibomian glands).
Anti-Androgen Therapy
Androgens, including testosterone, play a role in the function and structure of the meibomian and lacrimal glands. Low androgen levels, including those resulting from anti-androgen therapy, may lead to lower tear film stability, more evaporation of tears, and higher quantities of debris in tears.
Doctors use antipsychotic drugs to treat schizophrenia and other causes of psychosis. Many of these drugs can have a negative impact on eye health.
Older antipsychotics are known as “typical antipsychotics” and include haloperidol (Haldol). Newer ones are called “atypical” and include clozapine (Clozaril) and quetiapine (Seroquel).
Studies have found that clozapine was the most likely single antipsychotic to cause dry eye.
Taking clozapine with quetiapine further increased the risk.
If you think you have dry eye, it’s best to see an ophthalmologist or eye doctor. Addressing dry eye early may help prevent future eye problems.
The doctor will likely ask about your:
- Symptoms
- Medical history
- Medication use
- Lifestyle habits, such as smoking
They may then carry out a dilated eye exam. The doctor will put drops in your eye to widen the pupil before examining it.
They will look for signs such as inflammation or damage to the eye’s surface.
They may also measure:
- Tear volume In a Schirmer test, the doctor places blotting paper under your lower eyelid to see how much fluid collects in 5 minutes; in a phenol and red thread test, the doctor places a dye-filled thread over the lower eyelid for 15 seconds to see if the color alters due to a pH change.
- Tear quality Special dyes can reveal patterns on the eye’s surface linked to dry eye, along with tests to see how quickly tears evaporate.
- Tear osmolarity This test measures the composition of water to particles in tears; less water suggests dry eye.
- Biomarker tests The doctor takes tear samples to test in a laboratory for biomarkers of other diseases.
The doctor will then assess all of these factors to identify the most likely cause.
If a physician suspects your dry eye is due to a drug you’re taking, they may suggest you ask your prescribing doctor to assess your medication and possibly substitute a different drug.
However, the picture can be complex, Dr. Galor says, and simply identifying a single drug as the problem and eliminating it may not be the solution.
Solutions for treating dry eye caused by a medication might involve:
- Lowering the dose of the drug
- Changing to another drug
- Using artificial tears, available over the counter
- Applying ointments and gels to improve comfort
- Using prescription drugs “off label” to help increase tear production, such as cyclosporine (Restasis) or lifitegrast (Xiidra)
- Applying tear duct plugs to stop tears from draining away too fast
- Using a humidifier
- Avoiding smoky atmospheres
- Avoiding or quitting smoking
- Keeping air from blowing into your eyes, as with a hair dryer
- Positioning your computer screen below eye level so you don’t open your eyes so wide
- Closing your eyes for a few minutes when in a dry environment
- Taking screen breaks
- Wearing goggles or wraparound sunglasses
- Getting enough vitamin A and omega-3 oil in your diet
- A number of medications can cause or worsen dry eye, ranging from antihistamines to hormone therapies.
- Different drugs that cause dry eye have different biological pathways for creating the condition, and it’s not always clear why dry eye happens.
- Dry eye caused by medications usually stops when you stop taking the drug, but long-term use may cause permanent damage to eye tissue.
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