Dry Eye Disease and Ocular Surface Disorders in Endurance Athletes - A Narrative Review of Current Evidence and Prevention Strategies
DOI:
https://doi.org/10.12775/QS.2026.68.74355Keywords
Dry eye disease, ocular surface, tear film, endurance athletes, prevention, meibomian gland dysfunction, ultraviolet radiation, swimming, running, cyclingAbstract
Background. Endurance athletes (long-distance runners, cyclists, triathletes, swimmers, rowers, cross-country skiers) are repeatedly exposed to wind, ultraviolet radiation, low humidity, chlorinated water, air pollution, and autonomic stress that may compromise tear film homeostasis. Despite growing clinical interest, dry eye disease in this population remains under-recognized.
Aim. To synthesize current evidence on the prevalence, pathophysiology, clinical presentation, diagnostic findings, and prevention of dry eye disease and ocular surface disorders in endurance athletes.
Material and methods. A structured narrative review was conducted using PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar (2016–2025), with priority given to systematic reviews, meta-analyses, and the TFOS DEWS II and III reports.
Results. Endurance athletes show a markedly higher prevalence of dry eye symptoms and signs than age-matched non-athletic controls, with the evaporative subtype predominating. Convergence of environmental, mechanical, autonomic, and inflammatory stressors produces cumulative ocular surface damage that is often clinically silent. Evidence supports pre-, intra-, and post-exercise prevention strategies, including protective eyewear, eyelid hygiene, preservative-free artificial tears, environmental modification, and targeted anti-inflammatory therapy.
Conclusions. Dry eye disease in endurance athletes is multifactorial, predominantly evaporative, and largely preventable. Sport-specific, evidence-based prevention should be integrated into routine sports medicine practice, and further prospective longitudinal research is needed.
References
1. Stapleton F, Alves M, Bunya VY, Jalbert I, Lekhanont K, Malet F, Na KS, Schaumberg D, Uchino M, Vehof J, Viso E, Vitale S, Jones L. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334–365. https://doi.org/10.1016/j.jtos.2017.05.003.
2. Tsubota K, Pflugfelder SC, Liu Z, Baudouin C, Kim HM, Messmer EM, Kruse F, Liang L, Carreno-Galeano JT, Rolando M, Yokoi N, Kinoshita S, Dana R. Defining dry eye from a clinical perspective. Int J Mol Sci. 2020;21(23):9271. https://doi.org/10.3390/ijms21239271.
3. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276–283. https://doi.org/10.1016/j.jtos.2017.05.008.
4. Bron AJ, de Paiva CS, Chauhan SK, Bonini S, Gabison EE, Jain S, Knop E, Markoulli M, Ogawa Y, Perez V, Uchino Y, Yokoi N, Zoukhri D, Sullivan DA. TFOS DEWS II Pathophysiology Report. Ocul Surf. 2017;15(3):438–510. https://doi.org/10.1016/j.jtos.2017.05.011.
5. Alves M, Asbell P, Dogru M, Downie LE, Gomes JAP, Hogg RE, Pinazo-Duran MD, Pult H, Schaefer T, Sfameni S, Starr C, Vidas R, Wolkoff P, Craig JP. TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface. Ocul Surf. 2023;29:1–52. https://doi.org/10.1016/j.jtos.2023.04.002.
6. Willcox MDP, Argüeso P, Georgiev GA, Holopainen JM, Laurie GW, Millar TJ, Papas EB, Rolland JP, Schmidt TA, Stahl U, Suarez T, Subbaraman LN, Uçakhan Ö, Jones L. TFOS DEWS II Tear Film Report. Ocul Surf. 2017;15(3):366–403. https://doi.org/10.1016/j.jtos.2017.03.006.
7. Navarro-Lopez S, Moya-Ramón M, Gallar J, Carracedo G, Aracil-Marco A. Effects of physical activity/exercise on tear film characteristics and dry eye-associated symptoms: a literature review. Cont Lens Anterior Eye. 2023;46(9):101854. https://doi.org/10.1016/j.clae.2023.101854.
8. Abokyi S, Mensah SN, Nyameteh-Korsah R, Kyei S, Dadzie EE. Differential effect of maximal incremental treadmill exercise on tear secretion and tear film stability in athletes and non-athletes. Exp Eye Res. 2022;214:108865. https://doi.org/10.1016/j.exer.2021.108865.
9. Stapleton F, Argüeso P, Asbell P, Azar D, Bosworth C, Chen W, Ciolino JB, Craig JP, Gallar J, Galor A, Gomes JAP, Jalbert I, Jie Y, Jones L, Konomi K, Liu Y, Merayo-Lloves J, Oliveira FR, Perez VL, Rocha EM, Sullivan BD, Sullivan DA, Vehof J, Vitale S, Willcox M, Wolffsohn JS, Dogru M. TFOS DEWS III: Digest. Am J Ophthalmol. 2025 Nov;279:451-553. https://doi.org/ 10.1016/j.ajo.2025.05.040. Epub 2025 Jun 4. Erratum in: Am J Ophthalmol. 2026 Aug;288:350-351. https://doi.org/ 10.1016/j.ajo.2026.04.007.
10. Perez VL, Craig JP, Gomes JAP, Jones L, Markoulli M, Nelson JD, Nichols JJ, Sullivan DA, Tomlinson A, Vehof J, Stapleton F. TFOS DEWS III Executive Summary. Am J Ophthalmol. 2026;282:135–145. https://doi.org/10.1016/j.ajo.2025.09.035.
11. Sullivan DA, Rocha EM, Aragona P, Clayton JA, Ding J, Golebiowski B, Hampel U, McDermott AM, Schaumberg DA, Srinivasan S, Versura P, Willcox MDP. TFOS DEWS II Sex, Gender, and Hormones Report. Ocul Surf. 2017;15(3):284–333. https://doi.org/10.1016/j.jtos.2017.04.001.
12. Iqbal S, Rauf A, Park HJ, Choi HS. Impact of particulate matter and air pollution on ocular surface disease: a systematic review of preclinical and clinical evidence. Ocul Surf. 2025;35:100184. https://doi.org/10.1016/j.jtos.2024.12.001.
13. Sun C, Chen X, Huang Y, Zou H, Fan W, Yang M, Yuan R. Effects of aerobic exercise on tear secretion and tear film stability in dry eye patients. BMC Ophthalmol. 2022;22:9. https://doi.org/10.1186/s12886-021-02230-9.
14. Arshad M, Carnt N, Tan J, Ekkeshis I, Stapleton F. Water exposure and the risk of contact lens-related disease. Cornea. 2019;38(6):791–797. https://doi.org/10.1097/ICO.0000000000001898.
15. Gomes JAP, Azar DT, Baudouin C, Efron N, Hirayama M, Horwath-Winter J, Kim J, Mehta JS, Messmer EM, Pepose JS, Sangwan VS, Weiner AL, Wilson SE, Wolffsohn JS. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511–538. https://doi.org/10.1016/j.jtos.2017.05.005.
16. Wolffsohn JS, Arita R, Chalmers R, Djalilian A, Dogru M, Dumbleton K, Gupta PK, Karpecki P, Lazreg S, Pult H, Sullivan DA, Tomlinson A, Tong L, Villani E, Yoon KC, Jones L, Craig JP. TFOS DEWS II Diagnostic Methodology Report. Ocul Surf. 2017;15(3):539–574. https://doi.org/10.1016/j.jtos.2017.05.001.
17. Downie LE, Ng SM, Lindsley KB, Akpek EK. Omega-3 and omega-6 polyunsaturated fatty acids for dry eye disease. Cochrane Database Syst Rev. 2019;12:CD011016. https://doi.org/10.1002/14651858.CD011016.pub2.
18. Eom Y, Kim HM, Lee JS, Kim KS, Song JS. Re-esterified triglyceride ω-3 fatty acids in dry eye disease: a randomized clinical trial. Ocul Surf. 2024;33:50–56. https://doi.org/10.1016/j.jtos.2024.04.004.
19. Lee G, Kim JH, Lee SM, Kim HJ. Evidence-based strategies for warm compress therapy in meibomian gland dysfunction. J Clin Med. 2024;13(15):4358. https://doi.org/10.3390/jcm13154358.
20. Jones L, Downie LE, Korb D, Benitez-Del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu C, McPheeters K, Murata M, Ong ES, Quinto GG, Saldanha IJ, Schmidl D, Starr CE, Viso E, Wolffsohn JS. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575–628. https://doi.org/10.1016/j.jtos.2017.05.006.
21. Jones L, Downie LE, Korb D, Benitez-Del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu C, McPheeters K, Murata M, Ong ES, Quinto GG, Saldanha IJ, Schmidl D, Starr CE, Viso E, Wolffsohn JS. TFOS DEWS III Management and Therapy Report. Am J Ophthalmol. 2025;279:289–386. https://doi.org/10.1016/j.ajo.2025.05.039.
22. Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ, Lin A, Maguire MG, Rhee DJ. Dry eye syndrome preferred practice pattern. Ophthalmology. 2019;126(1):P286–P334. https://doi.org/10.1016/j.ophtha.2018.10.023.
23. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. https://doi.org/10.1136/bmj.j4008.
24. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute; 2014. Available from: https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
25. Wolffsohn JS, Wang MTM, Bilkhu P, Hogg RE, Jones L, Karpecki PM, Mathew J, Penn JE, Pult H, Sheppard A, Sullivan DA, Tomlinson A, Vehof J, Craig JP. TFOS DEWS III Diagnostic Methodology Report. Am J Ophthalmol. 2025;279:387–450. https://doi.org/10.1016/j.ajo.2025.05.033.
26. Moe MC, Özmert E, Baudouin C, Binadra A, Crafoord S, et al. International Olympic Committee (IOC) consensus paper on sports-related ophthalmology issues in elite sports. BMJ Open Sport Exerc Med. 2023;9(3):e001644. https://doi.org/10.1136/bmjsem-2023-001644.
27. Papas EB. The global prevalence of dry eye disease: A Bayesian view. Ophthalmic Physiol Opt. 2021;41(6):1254–1266. https://doi.org/10.1111/opo.12888.
28. Vehof J, Snieder H, Jansonius N, Hammond CJ. Prevalence and risk factors of dry eye in 79,866 participants of the population-based Lifelines cohort study in the Netherlands. Ocul Surf. 2021;19:83–93. https://doi.org/10.1016/j.jtos.2020.11.005.
29. Wolffsohn JS, Wang MTM, Vidal-Rohr M, et al. Demographic and lifestyle risk factors of dry eye disease subtypes: a cross-sectional study. Ocul Surf. 2021;21:58–63. https://doi.org/10.1016/j.jtos.2021.04.001.
30. Britten-Jones AC, Wang MTM, Samuels I, Jennings C, Stapleton F, Craig JP. Epidemiology and risk factors of dry eye disease: considerations for clinical management. Medicina (Kaunas). 2024;60(9):1458. https://doi.org/10.3390/medicina60091458.
31. Xiao K, Li L, Zhang X, Ye Y, et al. Global prevalence of dry eye: a systematic review and meta-analysis. Cont Lens Anterior Eye. 2025;49:102627. https://doi.org/10.1016/j.clae.2025.102627.
32. Suárez-Cortés T, Merino-Inda N, Benitez-del-Castillo JM. Tear and ocular surface disease biomarkers: a diagnostic and clinical perspective for ocular allergies and dry eye disease. Exp Eye Res. 2022;221:109121. https://doi.org/10.1016/j.exer.2022.109121.
33. Zemba M, Ionescu MA, Pîrvulescu RA, Dumitrescu OM, Daniel-Constantin B, Radu M, et al. Biomarkers of ocular allergy and dry eye disease. Rom J Ophthalmol. 2023;67(3):250–259. https://doi.org/10.22336/rjo.2023.42.
34. Mejía-Salgado G, Rojas-Carabali W, Cifuentes-González C, Zárate-Pinzón L, Tellez-Zambrano E, et al. Specific clinical phenotypes of dry eye disease can predict the presence of ocular surface inflammation as measured by InflammaDry. Cont Lens Anterior Eye. 2025;48:102397. https://doi.org/10.1016/j.clae.2025.102397.
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