ARTICLE
Mechanisms of Visual Disturbance in Dry Eye
Shizuka Koh, MD
Abstract: Dry eye has been believed to be a chronic, symptomatic
ocular surface disease that affects vision in a limited manner, because it
is difficult to detect visual or optical changes using standard visual
acuity testing. In practice, common visual complaints associated with
dry eye include fluctuating vision with blinking, blurred vision, glare,
and eye fatigue. This review discusses our past and current under-
standing of visual disturbances in dry eye and the various tools
available for assessing visual function or optical quality. Tear film
instability and ocular surface damage are key factors in the core
mechanism underlying dry eye. The mechanisms of these vision-related
subjective symptoms of dry eye based on visual function, particularly
wavefront aberrations or light scattering, and the core mechanism of dry
eye are described. Tear film instability is associated with decreased
stability of postblink higher-order aberrations, leading to “fluctuating
vision with blinking” and with increased ocular forward light scattering,
leading to “glare.” Ocular surface damage in the overlying optical zone
(in the central corneal regions), is associated with increased higher-
order aberrations and increased corneal backward light scattering that
can lead to “blurred vision”. “Eye fatigue” occurs when patients with
dry eye struggle to see things under such visual symptoms.
Key Words: dry eye, visual complaints, quality of vision, wavefront
aberrations, light-scattering tear film, ocular surface damage
(Cornea 2016;35(Suppl):S83–S88)
T he 2007 Tear Film & Ocular Surface Society Dry Eye
Workshop listed “visual disturbance” as one of the main
symptoms of dry eye, and defined dry eye as “a multifactorial
disease of the tears and ocular surface that results in
symptoms of discomfort, visual disturbance, and tear film
instability, with potential damage to the ocular surface.”1
Because most patients with dry eye achieve a good best-
corrected visual acuity, except for advanced or severe cases, it
has been difficult to detect degraded visual function using
conventional visual acuity measurements. Recent advances in
the development of ophthalmological or optical devices have
Received for publication June 30, 2016; accepted July 4, 2016. Published
online ahead of print August 31, 2016.
From the Department of Ophthalmology, Graduate School of Medicine, Osaka
University, Suita, Osaka, Japan.
S. Koh has received seminar fees from Topcon. This study was partly funded
by a grant from the Ministry of Education, Culture, Sports, Science and
Technology, Japan (#22791659).
The author has no conflicts of interest to disclose.
Presented in part at The 21st Annual Meeting of the Kyoto Corneal Club,
November 27, 2015, Kyoto, Japan.
Reprints: Shizuka Koh, MD, Department of Ophthalmology, Graduate
School of Medicine, Osaka University, Room E7, 2-2 Yamadaoka, Suita,
Osaka 565-0871, Japan (e-mail: skoh@ophthal.med.osaka-u.ac.jp).
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enabled us to investigate degraded visual function in dry eye in
a variety of ways. This review article describes the conceptual
changes of visual disturbance in dry eye and how dry eye limits
and degrades patients’ quality of vision (QoV). Furthermore,
the mechanism of vision-related subjective symptoms in dry
eye is discussed based on objective optical quality (aberrations
and light scattering) and the core mechanism underlying dry
eye. In particular, the simulated visual performance of dry eye
using a wavefront sensor is illustrated.
PAST UNDERSTANDING OF VISUAL FUNCTION
IN DRY EYE
The importance of the tear film for vision was first
reported in the early 1990s by Rieger, who compared vision
and static perimetry results in dry eyes with and without the
use of artificial tears.2 In a subsequent study, he reported that
the instillation of artificial tears improved contrast sensitivity
in patients with dry eye.3 In the late 1990s, Rolando et al.
reported the influence of the tear film on the modulation
transfer function of the ocular surface by demonstrating low
spatial-contrast sensitivity in dry eyes. In addition, they
reported improved spatial-contrast sensitivity with a tear
substitute.4 It is likely that, in that era, researchers had
a greater interest in developing better diagnostic methods or
tools for dry eye, partly because there was a very limited
repertoire of commercially available dry eye treatments
compared with the current era. Few studies focused on the
effect of artificial eye drops on vision in dry eye, and little
attention was directed toward the investigation of vision
associated with tear film behavior.
The growth and development of refractive surgery
marked a major turning point in ophthalmology. It fully
recognized the significance of quantitative evaluation of QoV,
instead of relying on visual acuity results measured using
conventional visual acuity tests. There has been a growing
emphasis on the improvement of QoV, not only in the field of
refractive surgery but also in ophthalmological treatments and
surgeries that are currently important in refractive correction
methods such as contact lenses or intraocular lenses. Against
this backdrop, there have been further developments in the
objective assessments of visual function. Quantitative optical
sampling devices such as corneal topographers or wavefront
sensors have been widely used in clinical practice and have
facilitated further study on QoV related to tear film behavior in
dry eye.
A number of studies using corneal topographers5–8 or
wavefront sensors9–13 have investigated the optical qualities
associated with the tear film and ocular surface to further our
understanding of QoV in dry eye. Moreover, increasing
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Koh Cornea  Supplement to Volume 35, Supplement 11, November 2016
attention to alternations or fluctuations in the tear film,
a specific characteristic feature of the tear film, has expanded
the ability for continuous capture of optical quality data.
Temporal changes in optical quality associated with tear film
behavior have been investigated using sequential measure-
ments of corneal topographic data14–16 or wavefront aberra-
tions.17–24 In addition, newly developed continuously
functional visual acuity measurement systems have shown
the visual performance associated with the tear film
alternation.25–27 In recent years, the double-pass tech-
nique28–32 or light-scattering measurements33,34 have been
used to reveal optical quality related to precorneal tear film
or ocular surface conditions.
VISUAL COMPLAINTS ARE PREVALENT AMONG
PATIENTS WITH DRY EYE
Visual complaints are common among patients with
dry eye in clinical practice. Several dry eye questionnaires
are in current use, although no specific unified question-
naires have currently been reported.35–43 Common visual
complaints associated with dry eye include fluctuating
vision with blinking, blurred vision, glare, and eye fatigue
(Fig. 1). Because dry eye may exhibit chronicity, these
symptoms sometimes show fluctuating severity. Further-
more, these subjective symptoms are generally common in
patients who visit eye clinics; therefore, some dry eye cases
may be diagnosed as unidentified troublesome complaints
without a definite dry eye diagnosis. This partly results from
dry eye conditions not being sight-threatening in most
patients and also results from most patients with dry eye
having a good best-corrected visual acuity except for
advanced cases. Recently, the importance of recognizing
ocular surface diseases that seem normal but that cause
many symptoms such as mild dry eye or short tear film
breakup time (BUT)-type dry eye has been emphasized. It is
important to note that tear film instability and ocular surface
damage are key factors in the complicated mechanisms of
dry eye (Fig. 1).1 Furthermore, a vicious circle between tear
film and ocular surface damage causes the dry eye
condition. To date, nonexistent or weak correlations have
been reported between subjective symptoms and clinical
signs,37,44–47 making dry eye a complicated disease. Fur-
thermore, little has been reported regarding a correlation
between objective optical quality data and subjective
symptoms in dry eye. One study from France reported that
the progression index for corneal higher-order aberrations
(HOAs) was correlated with the subjective index of the
patient-reported visual outcomes [Ocular Surface Disease
Index score] in dry eye.48
ABERRATIONS AND LIGHT SCATTERING IN
DRY EYE
In human eyes, aberrations and light scattering are the
main causes of optical quality degradation.33 In the remain-
ing sections, I speculate on the mechanisms involved in
subjective symptoms of dry eye based on aberrations and
light scattering.
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FIGURE 1. Core mechanism underlying dry eye and common
visual complaints associated with dry eye. (Upper panel) Core
mechanism underlying dry eye. Tear film instability and ocular
surface damage are key factors in the core mechanism under-
lying dry eye, and the vicious circle between tear film and ocular
surface damage causes dry eye. (Lower panel) Common visual
complaints associated with dry eye. Common visual complaints
associated with dry eye include “fluctuating vision with blink-
ing”, “blurred vision”, “glare”, and “eye fatigue”.
Aberrations
In eyes with corneal or ocular surface disorders,
aberrations are caused by an irregularity of refractive surfaces
in the anterior/posterior corneal surfaces and/or precorneal
tear film. Aberrations include lower-order components and
higher-order components. Conventional visual acuity tests
measure lower-order components such as sphere and cylinder;
however, they cannot detect HOAs. Wavefront sensors are
used to evaluate quantitative aberrations of the whole eye.49
Previous studies reported that they are sensitive enough to
detect optical changes associated with tear film breakup9–13
and increased HOAs after tear film breakup can even be
observed in normal eyes.10,12 To understand fluctuating or
changeable vision in dry eye, sequential ocular measurements
of ocular HOAs are useful. As demonstrated in Figure 2A,
visual performance is believed to be stable between blinks in
normal eyes without dry eye.19 The simulated retinal images
of a case of the short BUT type of dry eye or dry eye with
decreased tear film wettability are shown in Figure 2B.23
Generally, these disorders are characterized by decreased tear
film stability with severe dry eye symptoms including visual
complaints. They are often accompanied by little ocular
surface damage and an absence of tear deficiency. It was
reported that the postblink HOA pattern exhibits an upward
curve that continues to increase in the short BUT type of dry
eye. As shown in Figure 2B, the simulated retinal image is
good just after the blink; however, deterioration in image
quality is observed as the tear film stability decreases. This
explains the symptom of “fluctuating vision with blinking”
in dry eye. The simulated retinal image of a representative
case of aqueous tear-deficient dry eye is shown in Figure
2C.23 Retinal image quality is impaired even immediately
after the blink and remained poor between the blinks. It was
reported that sequential HOAs exhibited consistently greater
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Cornea  Supplement to Volume 35, Supplement 11, November 2016 Mechanisms of Visual Disturbance in Dry Eye

FIGURE 2. Representative sequential wavefront color-coded maps of postblink ocular HOAs and the simulated retinal images of
a Landolt ring. Wavefront data were obtained every 1 second after the blink with the wavefront sensor and the Landolt ring
(optotype with a logMAR value of 0); (A) normal eye. Visual performance is stable throughout, after the blink. Reprinted with
permission from Koh et al19 with modification. B, Short BUT type of dry eye. The simulated retinal image is normal just after the
blink; however, deterioration in image quality is observed as the tear film stability decreases. This explains the symptom of
“fluctuating vision with blinking” in the short BUT type of dry eye. Reprinted with permission from Koh et al.23 C, Dry eye with SPK
in the central corneal region. The simulated retinal image quality is impaired immediately after the blink and remains poor
between blinks. This explains the symptom of “blurred vision” in dry eye. Reprinted with permission from Koh et al24 with
modification.

values because of the very low tear volume that might be
responsible for the absence of sequential alternations in
HOAs.23 Increased ocular HOAs associated with superficial
punctate keratopathy (SPK) in the central corneal region
have been reported.23,50 In clinical practice, patients with
moderate or severe dry eye with SPK in the central corneal
region have an increased frequency of visual symptoms that
may become constant. Sequentially measured ocular HOA
results can explain the symptom of “blurred vision” in
dry eye.
Light Scattering
Light scattering can be subdivided into forward light
scattering and backward light scattering.33,51 Ocular forward
light scattering produces a veiling luminance on the retina.
This phenomenon may lead to glare.52 Commercially avail-
able devices use a double-pass imaging technique or a stray-
light meter to enable the measurement of forward light
scattering. In contrast, corneal haze with decreased corneal
transparency is typically determined by corneal backward light
scattering, which can be estimated by slit-lamp examination or
with a Scheimpflug camera. Clinically, forward light scat-
tering is more often associated with visual complaints than
backward light scattering. There have been fewer studies
investigating light scattering compared with aberrations in
dry eye. In addition to the limited commercially available
tools for light-scattering measurements, possible reasons for
this may include the complex relationships between ocular
forward light scattering and corneal backward light scatter-
ing.53–55 Furthermore, the existence of scatter-producing
microaberrations associated with tear film breakup has been
reported, which may cause difficulty in the interpretation of
light-scattering results.56
A previous study33 investigated both ocular forward
light scattering and corneal backward light scattering in 2 dry
eye groups with and without the presence of SPK in the
central corneal region. They reported that ocular forward light
scattering measured with a straylight meter was significantly
increased in both dry eye groups compared with normal eyes
(Fig. 3A). Because tear film stability decreased in both dry
eyes, it was speculated that tear film instability may be

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Koh Cornea  Supplement to Volume 35, Supplement 11, November 2016

FIGURE 3. Comparison of ocular

forward light scattering and corneal
backward light scattering in 2 dry eye
groups with and without the presence
of SPK in the central corneal region
and the normal eye group. A, Ocular
forward light scattering measured with
a straylight meter was significantly
increased in both dry eye groups
compared with normal eyes. Repre-
sentative corneal images with fluores-
cein without and with SPK in the
central corneal region are shown. *P ,
0.01. B, Corneal backward light scat-
tering measured with a corneal densi-
tometry program of a Scheimpflug
camera was significantly increased in
dry eyes with central SPK. There was
no difference between dry eyes with-
out central SPK and normal eyes.
Representative corneal images with
fluorescein with SPK in the central
corneal region are shown. *P , 0.01.
Reprinted with permission from Koh
et al33 with modification.

responsible for the increased ocular forward light scattering.
This explains the symptom of “glare” in dry eye. The effect
of forward light scattering on visual performance based on
these findings is shown in Figure 4. Another study30
investigated forward light scattering in dry eyes using
a double-pass imaging technique and reported that increased
forward light scattering in dry eye could be related to tear
film instability, and that the objective scatter index did not
correlate with the corneal staining score. However, a signif-
icant increase in corneal backward light scattering was
detected in dry eyes with central SPK using a corneal
densitometry program of the Scheimpflug camera. There
was no difference between dry eyes without central SPK and
normal eyes (Fig. 3B). Moderate positive correlations were
reported between the severity of central SPK and corneal
backward light scattering.33 SPK caused by mechanical or
inflammatory phenomena may contribute to increased
corneal backward light scattering from the anterior part of
dry eyes. Although backward light scattering is less
associated with visual complaints compared with forward
light scattering, severe SPK may lead to the symptom of
“blurred vision” in dry eye.
MECHANISMS UNDERLYING VISUAL
DISTURBANCES IN DRY EYE
As mentioned previously, tear film instability and
ocular surface damage are the main component factors in
the core mechanism of dry eye, and a vicious cycle between
tear film and ocular surface damage causes dry eye conditions
(Fig. 5, upper panel). Because clinical characteristics of dry
eye are caused by a combination of these 2 factors (tear film
instability and ocular surface damage), distinguishing
between these 2 factors might be difficult. However, from
an optical point of view, speculation of the mechanisms
underlying vision-related subjective symptoms in dry eye
based on objectively assessed optical quality (aberrations and
light scattering) and knowledge of the core mechanism
underlying dry eye is possible (Fig. 5, lower panel). As
discussed, tear film instability can cause decreased stability

FIGURE 4. Potential effect of increased

forward light scattering. (Left panel)
Original image. (Right panel) Image
presented with increased forward light
scattering that explains the symptom
of “blurred vision” in dry eye.

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Cornea  Supplement to Volume 35, Supplement 11, November 2016
FIGURE 5. Mechanisms of vision-related subjective symptoms
in dry eye based on objectively measured optical quality and
the core mechanism underlying dry eye. (Upper panel) Core
mechanism underlying dry eye. (Lower panel) Relationship
between vision-related subjective symptoms and objectively
measured optical quality (aberrations and light scattering).
Tear film instability causes decreased stability of postblink
HOAs, leading to “fluctuating vision with blinking.” Tear film
instability is also responsible for increased ocular forward light
scattering, leading to “glare.” Ocular surface damage, partic-
ularly in the overlying optical zone (in the central corneal re-
gions), causes increased baseline HOAs after the blink and
increased corneal backward light scattering that can lead to
“blurred vision.” When patients with dry eye struggle to see
things under such conditions, they experience “eye fatigue.”
Italic text with a shaded box denotes vision-related subjective
symptoms, and text with a solid line box denotes findings
from aberrations and light-scattering studies. [ indicates
“increased” and Y indicates “decreased”.
of postblink HOAs such as an upward pattern in postblink
HOA changes, leading to “fluctuating vision with blink-
ing.” Tear film instability is also responsible for increased
ocular forward light scattering, leading to “glare.” SPK,
particularly in the overlying optical zone (in the central
corneal regions), causes increased baseline HOAs after the
blink and increased corneal backward light scattering that
can lead to “blurred vision.” When patients with dry eye
struggle to see things under such conditions, they experi-
ence “eye fatigue.” Although not always explainable, such
speculations are consistent with previous findings.
A lack of association between signs and symptoms in
dry eye37,44–47 and objectively assessed optical quality and
subjective visual symptoms has been reported. In clinical
practice, some patients with severe dry eye complain of
only minor ocular symptoms including visual complaints,
even if they have severe corneal epithelial damage. When
visual performance cannot be explained by optical changes, it
may be attributed in part to neural factors. Because the neural
visual system compensates for long-term visual experience
with an asymmetrically blurred retinal image in keratoconic
eyes,57 a neural compensatory mechanism in severe dry eye
might occur, although further detailed investigation is needed.
Moreover, because a relationship between depression and dry
eye symptoms has been reported,58,59 psychological features
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Mechanisms of Visual Disturbance in Dry Eye
should be considered in some cases of dry eye. Therefore, dry
eye may be a multifactorial chronic symptomatic disease.1
CONCLUSIONS
This review presents possible mechanisms underlying
the visual disturbances in dry eye. Recently, comprehensive
diagnosis and treatment of dry eye have received increasing
attention. Because visual disturbances are present in the
definition of dry eye in the 2007 Dry Eye Workshop report,1
QoV associated with dry eye has received increasing
attention. Accordingly, quantitative objective assessment
of optical quality or visual function plays an important role.
Given that both tear film instability and ocular surface
damage lead to visual disturbances in dry eye, management
of dry eye by improving tear film stability is essential in
improving QoV in dry eye. The lack of association between
objectively assessed optical quality and subjective visual
symptoms in dry eye remains to be solved and is a challenge.
There is an unmet need for techniques that measure visual
functions that correlate with the vision-related subjective
symptoms of dry eye. Further developments of newly
evolved techniques and improvement or modifications of
existing devices are expected. To achieve this, combinations
of techniques are also possible. It would be ideal if useful
measurement techniques could be used in every clinic
worldwide, with the aim of providing better dry eye
diagnosis and treatment to alleviate the symptoms with
better patient QoV.
ACKNOWLEDGMENTS
The author thanks Prof. Thomas J.T.P. van den Berg
(Netherlands Institute for Neuroscience, Institute of the Royal
Netherlands Academy of Arts and Sciences, Amsterdam, the
Netherlands), Prof. Naoyuki Maeda and Prof. Kohji Nishida
(Department of Ophthalmology, Osaka University Graduate
School of Medicine, Suita, Japan) for assistance.
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