Medications that cause dry eyes: the main classes

If a medicine is drying your eyes, it is usually doing one of three things: damping down the watery part of your tears through an anticholinergic effect, changing the oil your eyelid glands make, or irritating the surface directly because it is a drop you are putting in several times a day. The classes that come up most often are antihistamines, tricyclic antidepressants and some other antidepressants, anticholinergics for bladder and gut problems, beta-blockers, diuretics, isotretinoin, hormonal contraceptives and menopausal hormone therapy, and glaucoma drops along with the preservatives they carry.

Two things before the detail. Most of this evidence is observational, so an association between a drug and dry eye symptoms is not proof the drug caused them. And more importantly: do not stop or change a prescribed medicine on the strength of an article. The eye problem is usually manageable alongside the drug, and the decision belongs to you and your prescriber. Tell them what your eyes are doing, and tell your optometrist what you are taking.

How a medicine ends up drying your eyes

The mechanisms are not exotic. Fraunfelder and colleagues, reviewing polypharmacy in dry eye disease, note that the mechanisms causing dry mouth differ little from those causing dry eye. That is a useful clue: if a medicine has left your mouth dry, it is a reasonable candidate for your eyes too.

The same review sets out three routes by which medicines may cause dry eye: through the drug’s therapeutic action, through effects on the ocular surface, or through preservatives. The authors note that these effects probably are additive, which matters if you take several things. They also observe that topical ocular polypharmacy has been shown to cause dry eye disease.

The TFOS DEWS II iatrogenic report describes the topical side in similar terms. Topical medications can cause dry eye disease through allergic, toxic and immuno-inflammatory effects on the ocular surface, and preservatives such as benzalkonium chloride may further aggravate it. A variety of systemic drugs can also induce it by multiple mechanisms.

The classes that come up most often

The right-hand column below matters, because the strength of evidence varies a great deal across a list that is usually presented as though it were uniform.

What the largest study actually found

The most useful single piece of evidence here is a Dutch population study by Wolpert and colleagues. They assessed 79,606 participants aged 20 to 97, 59.2% of them female, from the Lifelines cohort, using the Women’s Health Study dry eye questionnaire. Every medication was coded, and they tested the 59 most-used therapeutic subgroups and the 99 most-used individual drugs against dry eye symptoms, correcting for age, sex, body mass index and 48 comorbidities associated with dry eye.

Correcting for age and sex alone, 38 of the 59 subgroups and 52 of the 99 individual drugs were associated with dry eye symptoms, which on its own makes almost every medicine look guilty. The important part is what survived the fuller analysis. Once the 48 comorbidities were accounted for, the associations the authors describe as highly significant were drugs for peptic ulcer, particularly proton pump inhibitors, antiglaucoma medications, and anticholinergic medications.

Their conclusion is the practical lesson: correction for underlying comorbidities is critical to avoid confounding effects. Much of the apparent link between a medicine and dry eye is really the link between the illness and dry eye. The authors singled out the novel connection with proton pump inhibitors as deserving attention, given how commonly they are prescribed. This study measured symptoms by questionnaire at a single point in time, so it cannot tell us a drug caused anything.

On hormone therapy, the clearest signal comes from the Women’s Health Study of 25,665 postmenopausal women. The multivariable-adjusted odds ratio for either clinically diagnosed dry eye syndrome or severe symptoms was 1.69 for oestrogen alone and 1.29 for oestrogen plus progesterone or progestin, against no use, and each three-year increase in duration carried a 15% elevation in risk. Our piece on dry eyes and menopause puts that in context.

Your eye drops are medicines too

People think of tablets when they think of drug-induced dryness, but drops are often the bigger contributor: they land directly on the tissue in question, and many are used several times a day for years. Fraunfelder and colleagues concluded that long-term use of topical ocular medications, especially those containing preservatives such as benzalkonium chloride, may play an important role in dry eye disease.

This matters most if you are on glaucoma treatment, where drops are lifelong and often more than one bottle. Preservative-free formulations exist for several of these medicines, but whether one suits you is a conversation with the clinician managing your pressures. The same logic applies to any preserved drop used heavily, including over-the-counter lubricants, so preservative-free is conventionally preferred past about four doses a day. Our guide to prescription dry eye drops covers the treatment side.

What to do if you think a medicine is involved

Start with timing. Did the dryness appear or worsen within a few weeks of starting something new, or of a dose increase, and did your mouth go dry at the same time? Then take a complete list to your appointment: prescriptions, eye drops, supplements and anything bought over the counter, because antihistamines and some sleep aids are easy to forget.

The next step is working out what kind of dry eye you have, since that determines what helps. An anticholinergic reducing tear volume and isotretinoin acting on the oil glands are different problems needing different treatment, and this piece explains how the two are told apart. A standard assessment, described in our guide to dry eye tests, usually sorts it out in one visit.

In most cases the answer is not a change of medication at all. It is treating the surface properly while the medicine continues: lubricants matched to the type of dryness, lid care where the margins are involved, and attention to screens and air conditioning. A consistent daily routine does more here than any single product.

Where the assessment shows the meibomian glands are involved, which is typical with isotretinoin, warming the lids is a first-line, guideline-recommended step for that component. The Meibocare E-Heated Eye Mask is designed to bring the eyelids to about 42 °C on the recommended setting and timer, and it is notified to Medsafe on the New Zealand WAND database (240927-WAND-746QNT), a register that records notifications rather than assessing them. Heat addresses the oil layer, and does nothing about a drug’s effect on the watery part of your tears.

Heat therapy is not something to begin unsupervised in every eye: an infection, recent eye surgery, glaucoma or any change in vision are all reasons to speak to your optometrist or ophthalmologist first, and to check in with them if you are already using it.

Frequently asked questions

Which medications most commonly cause dry eyes?

Anticholinergic drugs, such as bladder antimuscarinics and the older sedating antihistamines, are the classic group, because they reduce watery secretion. A large Dutch population study of 79,606 people found the strongest associations with anticholinergics, antiglaucoma medications and peptic ulcer drugs, particularly proton pump inhibitors, after adjusting for other illnesses. Antidepressants, beta-blockers, diuretics, isotretinoin and hormone therapy are also commonly listed.

Should I stop my medication if it is drying my eyes?

No. Never stop or change a prescribed medicine because of eye symptoms without talking to the person who prescribed it. In most cases the dryness can be managed alongside the drug with lubricants, lid care and environmental changes, and the medicine continues unchanged. If a change is genuinely needed, your prescriber can weigh alternatives against the reason you were prescribed it.

Can eye drops themselves cause dry eye?

Yes. The TFOS DEWS II iatrogenic report states that topical medications can cause dry eye disease through allergic, toxic and immuno-inflammatory effects on the ocular surface, and that preservatives such as benzalkonium chloride may further aggravate it. This matters most with drops used several times daily over years, such as glaucoma treatment. Ask your prescriber whether a preservative-free version is available.

Does hormone replacement therapy increase dry eye risk?

The Women’s Health Study followed 25,665 postmenopausal women and found multivariable-adjusted odds ratios of 1.69 for oestrogen alone and 1.29 for oestrogen with progesterone or progestin, compared with no hormone replacement therapy. Each three-year increase in duration of use carried a 15% higher risk. The authors suggested physicians caring for women taking or considering it should be aware of this potential complication.

Educational information only, not medical advice. References: Fraunfelder FT, et al. J Ophthalmol. 2012;2012:285851; Wolpert LE, et al. Ocul Surf. 2021;22:1–12; Gomes JAP, et al. Ocul Surf. 2017;15:511–538; Schaumberg DA, et al. JAMA. 2001;286:2114–2119.