What guides treatment decisions in dry eye disease: Signs or symptoms?

To determine whether patient-reported symptoms or clinical signs more strongly influence dry eye disease (DED) treatment decisions and how decisions are made during sign-symptom discordance.

A cross-sectional survey was distributed via listservs to practicing optometrists (ODs) and ophthalmologists (OPH) who treat DED. Respondents reported demographic and practice characteristics and selected factors influencing treatment initiation, management of sign-symptom discordance, and definitions of treatment success. Group comparisons were analyzed using Chi-square/Fisher's exact tests and t-tests, focusing on OD vs. OPH differences.

208 clinicians participated (98 OPHs, 110 ODs). While most relied on a combination of signs and symptoms to initiate treatment, clinical severity heavily influenced decisions; clinicians were highly likely to initiate treatment for moderate-severe symptoms even when signs were minimal (OPH 79.8%, OD 70.5%) and to treat moderate-severe signs in asymptomatic patients (OPH 63.8%, OD 60.6%). However, symptoms were ultimately weighted more heavily for treatment initiation (OPH 61.7% vs. OD 49.0%). Only 1.1% of ophthalmologists and 5.2% of optometrists felt that signs and symptoms "frequently" correlate. When evaluating treatment success, both groups again prioritized symptom severity, selecting symptom improvement - either alone or over signs - as the primary indicator (OPH 78.7%, OD 66.6%). Ocular surface staining was rated the most influential clinical sign, followed by tear break-up time and eyelid abnormalities; tear osmolarity and MMP-9 were rated least influential.

Clinicians routinely navigate sign-symptom discordance by treating high clinical severity in either domain, though subjective symptoms ultimately exert a heavier influence on initial therapy choices and determinations of success. Decision-making patterns were similar across clinician types, underscoring the central role of patient-reported symptoms in real-world DED management.