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Ocul Surf. 2017 Jul;15(3):511-538. doi: 10.1016/j.jtos.2017.05.004. Epub 2017 Jul 20.

TFOS DEWS II iatrogenic report.

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Dept. of Ophthalmology and Visual Sciences, Federal University of Sao Paulo/Paulista School of Medicine (UNIFESP/EPM), São Paulo, SP, Brazil. Electronic address:
University of Illinois College of Medicine, Chicago, IL, USA.
Quinze-Vingts National Eye Hospital & Vision Institute, Paris, France.
School of Optometry and Vision Science, Queensland University of Technology, Queensland, Australia.
Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan.
Department of Ophthalmology, Medical University Graz, Austria.
Duke University School of Medicine, Durham, NC, USA; Duke University Eye Center, Durham, NC, USA.
Singapore National Eye Centre, Singapore.
Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany.
Washington University School of Medicine, St. Louis, MO, USA.
L V Prasad Eye Institute, Hyderabad, India.
DrugDel Consulting, LLC, Peoria, AZ, USA.
Cole Eye Institute, The Cleveland Clinic, Cleveland, OH, USA.
Aston University, Birmingham, UK.


Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.


Contact lens; Cosmetic; Drug related adverse reactions; Drug related side effects; Drug toxicity; Dry eye; Iatrogenic disease; Surgery

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