Can Benzodiazepines Cause Dry Eyes?
Yes, benzodiazepines (benzos) are associated with dry eye disease and can exacerbate dry eye symptoms through multiple mechanisms that disrupt tear production and ocular surface homeostasis.
Evidence from Clinical Guidelines
The most recent American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern (2024) explicitly identifies antianxiety medications as a risk factor for dry eye disease 1. This guideline, based on the Beaver Dam Eye Study update, found that antianxiety medications were among the additional risk factors associated with dry eye development 1.
The 2019 version of the same guideline similarly confirmed that antidepressant and antianxiety medications were identified as risk factors for dry eye in population-based studies 1.
Mechanism of Action
Benzodiazepines contribute to dry eye through several pathways:
Anticholinergic effects: Benzodiazepines possess anticholinergic properties that disrupt the efferent cholinergic nerves responsible for stimulating tear secretion 1
Reduced tear production: These medications interfere with the normal maintenance of the tear film by decreasing aqueous tear production 2
Sleep-related mechanisms: A Chinese study found that sedative-hypnotic medications (which include benzodiazepines) may be associated with dry eye development in patients with sleep disorders 1
Neuromuscular effects: Benzodiazepines can cause disturbances in eye movements and blinking patterns, which may compromise tear film distribution 3
Clinical Significance and Quality of Life Impact
The association between benzodiazepines and dry eye is clinically relevant because:
Dose-dependent effects: The adverse effects on dry eye may be dose-related and can potentially be relieved by reducing the dosage 2
Elderly populations at highest risk: A 2020 study found that among aged care residents with documented dry eyes or using ocular lubricants, half were taking medications known to cause or aggravate dry eyes 4
Reversibility: Eliminating the offending medication can reverse symptoms and prevent further deterioration of ocular surface inflammation 5
Management Algorithm
When a patient on benzodiazepines presents with dry eye symptoms:
Confirm the diagnosis: Look for fluctuating vision, ocular irritation symptoms worse at end of day, and punctate epithelial erosions on dye staining 1
Assess severity: Evaluate for moderate-to-severe pain, corneal infiltration/ulceration, or progressive conjunctival scarring that would require ophthalmology referral 1
Consider medication adjustment:
Initiate symptomatic treatment:
Important Clinical Pitfalls
Multiple medication effects: Patients on benzodiazepines often take other medications that worsen dry eye (antihistamines, antidepressants, diuretics), creating an additive effect 1, 7
Preserved eye drops: If patients use more than 4 drops daily of preserved artificial tears, this can paradoxically worsen symptoms through corneal epithelial breakdown 1, 7
Younger patients and males: Dry eye in these populations while on benzodiazepines should raise suspicion for underlying systemic conditions beyond medication effects 1, 7
Environmental factors: Low humidity, air conditioning, and increased screen time can significantly exacerbate benzodiazepine-induced dry eye 6, 7
When to Refer to Ophthalmology
Patients require ophthalmology consultation if they experience 6:
- Moderate or severe eye pain
- Lack of response to over-the-counter lubricating drops
- Progressive worsening of vision
- Symptoms significantly impacting quality of life