Dry eye disease in thyroid eye disease: A narrative review of pathogenic mechanisms and therapeutic implications

Abstract

Dry eye disease (DED) is a common and persistent manifestation of thyroid eye disease (TED), often remaining symptomatic despite apparent control of orbital inflammation or systemic thyroid dysfunction. This narrative review synthesizes current evidence within an integrated mechanistic framework relating the overlapping contributors to TED-associated DED to disease phenotype, therapeutic limitations, and opportunities for more targeted management. A literature review was conducted using PubMed and Scopus through March 2026, using broad MeSH and free-text terms related to TED, DED, ocular surface disease, and treatment, with manual screening of relevant references. Current evidence suggests that DED in TED reflects coordinated disruption of tear film homeostasis involving glandular, evaporative, inflammatory, epithelial/mucin, and neuro-sensory pathways rather than a single mechanism such as exposure or reduced tear production. The relative contribution of these pathways may vary according to disease activity and individual ocular surface phenotype. Recognition of the dominant contributors in individual patients may support a shift from uniform symptom-directed lubrication toward phenotype-directed ocular surface management. Emerging neuro-regenerative and regenerative therapies remain investigational because TED-specific evidence is limited.