A longitudinal study published in Optometry and Vision Science found suggestive evidence that perceived stress may precede worsening dry eye symptoms in young adults. However, the prospective association was small and reached statistical significance only with a prespecified 1-tailed test.1
Both perceived stress and dry eye symptom scores increased significantly during approximately 7.5 months of follow-up. The findings underscore the potential relevance of psychological and environmental context when evaluating patients with dry eye complaints, but they do not establish stress as a cause of ocular surface disease.
“These findings provide suggestive, but not confirmatory, evidence of a small prospective association between earlier perceived stress and later dry eye symptom burden in a sample of predominantly young adult women,” the study authors, led by Reut Ifrah, PhD, of the Department of Optometry and Vision Science at the Jerusalem Multidisciplinary College in Jerusalem, Israel, stated. "However, the finding should be interpreted cautiously given the modest sample size, the two-wave design, and its dependence on a directional one-tailed test. Further longitudinal studies are needed.”
Study overview
Investigators used a 2-wave, cross-lagged panel design to examine the temporal relationship between perceived stress and dry eye symptoms. The study included 71 young adults, of whom 60 were female. Participants had a mean age of 22 ± 3 years.1
Key facts
- Study topic: Temporal association between perceived stress and dry eye symptoms
- Journal and date: Optometry and Vision Science; published online August 6, 2026
- Design: Two-wave cross-lagged panel study
- Population: 71 young adults; 60 female; mean age, 22 ± 3 years
- Exposure: Perceived stress measured with the PSS-14
- Primary outcome: Dry eye symptoms measured with the OSDI
- Key result: Earlier stress showed a small association with later symptoms (β = 0.18), significant only with the prespecified 1-tailed test
- Major limitation: Small, predominantly female sample and reliance on 2 waves of self-reported data
At both assessments, participants completed the 14-item Perceived Stress Scale (PSS-14) and the Ocular Surface Disease Index (OSDI). The assessments occurred approximately 7.5 months apart, with the second conducted during a period of heightened regional threat.
The researchers used paired-samples t tests to evaluate changes over time, Pearson correlations to assess associations, and cross-lagged panel modeling to examine whether earlier stress predicted later dry eye symptoms or whether earlier dry eye symptoms predicted subsequent stress. Bootstrap confidence intervals also were applied.
The directional path from perceived stress at the first assessment to dry eye symptoms at the second was tested using a prespecified 1-tailed analysis. All other significance tests were 2-tailed.
Stress and dry eye symptoms
Mean perceived stress increased by 4.2 points during follow-up, a statistically significant change (t[70] = 6.20; P < .001). The standardized within-participant effect size was moderate to large (dz = 0.74).1
Dry eye symptoms increased by 7.5 points over the same period (t[70] = 3.46; P < .001), with a small to moderate effect size (dz = 0.41). Perceived stress and dry eye symptoms were positively associated at both time points, and each measure showed substantial rank-order consistency across assessments.
In the cross-lagged model, perceived stress at baseline had a small positive association with dry eye symptoms at follow-up (standardized β = 0.18). This relationship did not meet the conventional threshold for significance using a 2-tailed test (P = .084), although it was significant under the prespecified directional 1-tailed test (P = .042).
The reverse pathway—from initial dry eye symptoms to subsequent perceived stress—was smaller and was not statistically significant (β = 0.09). Thus, the results offered limited support for the hypothesis that stress may precede increased symptom burden, while providing no statistically significant evidence that dry eye symptoms predicted later perceived stress.
Clinical context
Dry eye disease is multifactorial, and patients’ reported symptom burden may reflect both ocular surface changes and broader psychophysiological processes. According to the investigators, previous research has linked dry eye symptoms with psychological distress, but predominantly cross-sectional studies have been unable to clarify temporal directionality.1
The study did not include objective ocular surface measures, and the findings should not be interpreted as evidence that symptoms are solely psychological or that stress management is an established dry eye treatment.
Limitations and future research
The modest sample size limited statistical power, and the predominantly female, young adult cohort may not represent older adults or the broader dry eye population. Both primary variables were assessed using self-reported questionnaires. In addition, the 2-wave design cannot characterize more complex or changing relationships over time.
The prospective finding also depended on a directional 1-tailed test and was not significant using a conventional 2-tailed threshold. The heightened regional threat at the second assessment may have affected stress and symptom reporting simultaneously.
Larger, more diverse multiwave studies are needed to determine whether perceived stress reliably predicts later dry eye symptoms. Future investigations should incorporate objective ocular surface measures and assess potential behavioral, environmental, and physiologic pathways underlying the association, the study authors stated.
Reference
Ifrah R, Gantz L, Besser A. The longitudinal association between perceived stress and dry eye symptoms: a cross-lagged panel study. Optom Vis Sci. Published online August 6, 2026. https://onlinelibrary.wiley.com/doi/10.1002/ovs2.70091
