In today’s fast-paced clinical world, it’s easy to stay focused on new technologies, new treatments, and the next patient waiting to be seen.
But sometimes it’s valuable to pause and look back.
- Where did our understanding of dry eye disease begin?
- How has it changed over time?
- And what can the past teach us about improving eye comfort and vision today?
These are the questions I explored in my opening address at OSI 2025. Dry eye disease has been a major part of my professional journey, and its history tells a fascinating story of observation, discovery, and constant evolution. As Sir Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.” This is especially true when we look at how far dry eye care has come.
Ancient Beginnings: Early Ideas About Tears and Eye Comfort
Our story starts over 3,500 years ago in Egypt, Mesopotamia, China, and the Indus Valley. These early civilisations combined practical care with spiritual belief, using natural remedies to soothe irritated eyes.
Egypt: the first written record of the tear film
The ancient Ebers Papyrus mentions “tear fluid and mucous secretion”, showing an early understanding of the tear film. Egyptians used natural ingredients like myrrh and incense for eye comfort, and even practised early forms of meibomian gland expression long before meibomian gland dysfunction (MGD) was recognised.
Mesopotamia: early written treatments
Clay tablets from around 650 BC list recipes for eye problems. Ingredients like onion, beer, oil, and frog’s gall sound strange today, but they represent some of the first attempts to treat eye discomfort in a structured way.
China and the Indus Valley: acupuncture and natural therapies
Traditional acupuncture, used as far back as 2500 BC, may help calm inflammation. In the Indus Valley, warm and cool compresses, eyewashes, and castor oil were used to relieve symptoms described as “diseases of the wind”, possibly early references to dry, irritated eyes.
Classical Civilisations: Early Clinical Descriptions
In ancient Greece, treatment was based on the balance of the four “humours”, and eye baths or even bloodletting were used to restore health.
By Roman times, eye problems were taken very seriously. Military records from the Vindolanda tablets show that eye issues were among the most common complaints of soldiers. Roman physicians also produced early portable eye medications called collyria, small stamped cakes dissolved into pastes.
The Roman writer Celsus gave one of the earliest clear descriptions of dry eye (then known as “xerophthalmia”):
“The eyes are red, heavy and painful at night, and the lids are stuck together by troublesome discharge.”
Anatomical Breakthroughs: Discovering the Tear System
Foundational scientific discoveries began in the 17th century and shaped our modern understanding of the ocular surface:
- 1666: Johann Meibom describes the meibomian glands.
- 1700s: Johann Zinn maps key eye structures.
- 1930s to 1940s: Henrik Sjögren identifies the autoimmune disease that now carries his name.
- 1946: Jules Wolff outlines the three-layer tear film model.
By the 1970s, the “ocular surface” was understood as a functional unit, a major step toward today’s holistic approach.
The Modern Era: Defining Dry Eye as a Disease
Much of what we now recognise as dry eye disease has been defined only in the last few decades.
Important milestones include:
- 1995: The lacrimal functional unit is formally introduced.
- 2007 TFOS DEWS: Dry eye reclassified as a disease, not a minor disorder.
- 2007 Baudouin: The “vicious cycle” model of dry eye is explained.
- 2011 TFOS MGD Report: Identifies MGD as the most common cause of dry eye.
- 2011 Korb and Blackie: Demonstrate the importance of gland expression.
- 2017 TFOS DEWS II: Recognises neuropathic pain and confirms MGD’s major role.
- 2021 BCLA CLEAR: Links inflammation, contact lenses, and ocular surface changes.
- 2023 TFOS Lifestyle Report: Reviews lifestyle triggers such as screen use and cosmetics.
- 2025 TFOS DEWS III: The most comprehensive update yet.
These advances helped create consistent definitions, clearer diagnostics, and more targeted treatment pathways.
Evolving Treatments: From Home Remedies to Modern Devices
Lid hygiene
Ancient compresses eventually evolved into early home remedies like teabags and baby shampoo. Baby shampoo, once popular, was later found to damage goblet cells, leading to the development of today’s safer, dedicated lid hygiene products.
Medical therapies
Prescription treatments also developed rapidly:
- 2003: Restasis introduces modern immunomodulatory therapy.
- Subsequent preservative-free options improved safety and comfort.
In-clinic treatments
From the 2010s onwards, new energy-based technologies broadened treatment options:
- LipiFlow
- BlephEx
- IPL and LLLT therapies
These allowed clinicians to treat the underlying causes rather than simply managing symptoms.
A New Era of Research and Collaboration
From the early 2000s onwards, research grew rapidly. Better imaging, improved diagnostics, and global collaboration through organisations such as TFOS, BCLA, and OSI helped unify best practice and accelerate progress.
Modern Challenges: Supporting Consistent, Confident Care
Despite huge advances, challenges remain:
- Limited consultation time
- Diagnostic uncertainty
- Costs of advanced equipment
- Patient compliance
- Variability in patient understanding and education
These contribute to what we call the Clinician Confidence Cycle, where hesitation can slow the adoption of effective dry eye management. Continued education and clear communication remain essential.
Conclusion: What the Past Teaches Us About the Future
From ancient herbal compresses to today’s advanced IPL and meibomian gland therapies, the history of dry eye disease shows how far we have come. Each discovery built on the work of earlier generations and moved us closer to the comprehensive, science-based approach we have today.
As new treatments and technologies continue to develop, our understanding of dry eye is stronger and more important than ever. By learning from the past while embracing innovation, we can shift dry eye care from simply treating symptoms to providing personalised, proactive, long-term relief.
We truly stand on the shoulders of giants, and the next generation will stand on ours.