Clinicians Prioritize Symptoms Over Signs in DED Management

A recent survey on OD/MD priorities in dry eye treatment decisions illustrates that “in real-world practice, patient experience often drives management decisions more than traditional diagnostic metrics,” remarks Kaleb Abbott, OD, one author of the survey. Photo: Luis Rojas, OD. Click image to enlarge. A team of researchers recently surveyed more than 200 optometrists and ophthalmologists to determine whether patient-reported symptoms or clinical signs have a greater influence on dry eye disease (DED) treatment decisions. The results, presented earlier this month at the annual ARVO meeting in Denver, indicated that clinicians seem to prioritize symptoms over signs in dry eye management, both when initiating therapy and determining treatment success.The cross-sectional survey was distributed via listservs and social media, receiving a total of 208 responses from 98 ophthalmologists and 110 optometrists. On average, male participants were older (54 vs. 44 years) and constituted a larger proportion of the sample (63% male vs. 46% female). Respondents provided demographic and practice information and indicated which factors influence treatment initiation, how they manage sign-symptom discordance and how they define treatment success.Most clinicians reported using both signs and symptoms to decide when to start treatment, though symptoms were given greater weight (MD 61.7% vs. OD 49.0%). Providers were very likely to treat patients with moderate-severe symptoms even when objective signs were minimal (MD 79.8%, OD 70.5%), and they were also likely to treat moderate-severe signs in asymptomatic patients (MD 63.8%, OD 60.6%). For assessing treatment success, both groups placed the highest importance on symptom improvement—either alone or prioritized over signs (MD 78.7%, OD 66.6%). Of the clinical signs, ocular surface staining was rated most influential (rank 1 to 10; MD 9.6, OD 9.2), followed by tear break-up time (MD 8.1, OD 7.1) and eyelid abnormalities (MD 6.6, OD 7.6); tear osmolarity and MMP-9 were considered the least influential. Kaleb Abbott, OD, one of the lead authors of this survey, comments, “One of the most surprising findings was just how strongly clinicians prioritized symptoms over signs in dry eye management.” He elaborates, “Providers were overwhelmingly willing to initiate treatment even when clinical signs were minimal or absent, as long as patients reported significant symptoms. Likewise, many clinicians still considered treatment successful if symptoms improved despite no objective improvement in ocular surface findings.” These findings, Dr. Abbott notes, suggest that “in real-world practice, patient experience often drives management decisions more than traditional diagnostic metrics.” He also brings up the irony of “dryness” being only the fifth most influential symptom “in so-called ‘dry eye disease,’” while higher ratings of importance were given to symptoms like burning, grittiness, fluctuating vision and foreign body sensation. “That really highlights how heterogeneous this condition is and raises the question of whether the term ‘dry eye’ is actually an accurate descriptor for many patients,” Dr. Abbott posits. Treatment decision patterns were similar between ODs and MDs, though Dr. Abbott reports that “ophthalmologists appeared to weigh symptoms even more strongly when defining treatment success.” He adds, “Optometrists still favored symptoms overall, but placed slightly greater emphasis on objective signs compared to ophthalmologists, particularly when evaluating outcomes.”These data imply that patient-reported symptoms predominantly guide real-world DED treatment decisions, which Dr. Abbott conveys is especially important to consider in industry and clinical trial design. “As therapies are increasingly developed for neuropathic ocular pain, chronic ocular surface pain, and neurotrophic keratitis, companies need to recognize that clinicians are strongly symptom-driven in their decision-making,” he says. “Therapies that improve symptoms without changing signs may still be viewed favorably by providers, while diseases like neurotrophic keratitis—where symptoms may be minimal despite severe pathology—could potentially be underrecognized if clinicians rely too heavily on symptom burden.”Original abstract ©2026 Association for Research in Vision and Ophthalmology.Click here for the source. Abbott K, Ifantides C, Christopher K, Auer E, Patnaik J. What drives dry eye treatment decisions? a survey of clinician priorities. ARVO 2026 annual meeting. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.