What medications can cause dry eyes?

Medications That Cause Dry Eyes

Multiple medication classes can cause or exacerbate dry eye disease, with antihistamines, antidepressants, anticholinergics, diuretics, and systemic retinoids being the most common culprits. 1, 2

High-Risk Medication Categories

Psychiatric and Neurological Medications

• Antidepressants and antianxiety medications are strongly associated with increased dry eye risk through disruption of efferent cholinergic nerves that stimulate tear secretion 1, 2
• Anticholinergic drugs directly interfere with tear production by blocking parasympathetic stimulation of the lacrimal gland 1
• Sedative-hypnotics used for sleep disorders may be associated with dry eye development 1, 2

Allergy and Cold Medications

• Antihistamines are consistently identified as a major risk factor for dry eye across multiple large epidemiological studies 1, 2
• These medications reduce tear secretion through their anticholinergic properties 3

Cardiovascular Medications

• Diuretics contribute to dry eye by reducing overall body fluid volume, including tear production 1, 2
• Beta-receptor blocking agents prescribed for cardiovascular problems can cause dry eye complaints 4
• Note: ACE inhibitors are actually associated with a lower risk of dry eye 1, 2

Dermatologic Medications

• Systemic retinoids (isotretinoin) for acne cause meibomian gland dysfunction and are particularly problematic 1, 2, 5
• This effect is dose-related and can sometimes be relieved by reducing dosage 3

Corticosteroids

• Oral corticosteroids increase dry eye risk through multiple mechanisms affecting the ocular surface 1, 2

Hormone Therapy

• Hormone replacement therapy, particularly estrogen use alone in postmenopausal women, significantly increases risk of clinically diagnosed dry eye 1, 2

Topical Ophthalmic Medications

Glaucoma Medications

• Topical glaucoma medications containing benzalkonium chloride (BAK) are a significant risk factor 1, 2
• Frequent use of any preserved eye drops (>4 drops daily) causes corneal epithelial breakdown from preservative toxicity 1, 2, 6, 7
• When using eye drops more than four times daily, preservative-free formulations are strongly recommended 6

Newer Anticancer Agents

• Immune checkpoint inhibitors cause lacrimal gland dysfunction 5
• Taxanes cause meibomian gland dysfunction 5
• Epidermal growth factor receptor (EGFR) inhibitors and fibroblast growth factor receptor (FGFR) inhibitors cause mucosal epitheliopathy 5
• Belantamab mafodotin causes mucosal epitheliopathy 5
• Gliptins can cause cicatrizing conjunctivitis 5

Clinical Management Approach

Assessment Strategy

When evaluating a patient with dry eye, systematically review their medication list for the above agents, paying particular attention to:

• Polypharmacy effects - multiple medications with anticholinergic or drying properties have additive effects 7
• Dose-related effects - some medications cause dry eye in a dose-dependent manner 3

Management Options

• Consider medication substitution within the same drug family if an alternative exists with less dry eye risk 3
• Reduce dosage when the adverse effect is dose-related and clinically appropriate 3
• Discontinue the offending medication when possible, as this can reverse symptoms and prevent further ocular surface deterioration 5
• Coordinate with prescribing physician before making any medication changes 5

Important Caveats

Protective Factors

• Caffeine use is associated with a decreased risk of dry eye 1, 2
• ACE inhibitors are associated with a lower risk compared to other antihypertensives 1, 2

Paradoxical Findings

• Multivitamin use is associated with an increased risk of dry eye, contrary to what might be expected 1, 2

Environmental Interactions

Environmental factors such as low humidity, air conditioning, and increased screen time can significantly worsen medication-induced dry eye 8, 6