Anticholinergic Burden May Elevate Dry Eye Disease Risk

Exercising greater caution when prescribing anticholinergic drugs may improve patient outcomes.

Anticholinergic burden, which refers to the cumulative effect of 1 or more drugs with anticholinergic activity, may be associated with an increased risk of dry eye disease (DED), according to a study published in Eye. 

“Ascertaining the full roles of systemic and topical drugs, which are among the etiologies of dry eye, is of great importance because this can provide clues about the multifactorial pathophysiology of dry eye and can help alleviate the clinical condition for patients by allowing the replacement of those drugs,” according to the study authors. 

Researchers included  106 study participants (61.3% women; mean age, 57.4 years) in the retroscopic analysis who underwent a comprehensive ophthalmic examination between February 2021 and February 2022. The team stratified participants according to DED status (DED: n=51; control group: n=55), obtained Schirmer 1 and Ocular Surface Disease Index (OSDI) scores, and determined anticholinergic burden using the Anticholinergic Cognitive Burden (ACB) scale (0, no anticholinergic effects; 1, possible anticholinergic effects; 2-3, definite anticholinergic effects).  

Patients with DED had significantly higher Charlson comorbidity index scores, lower Schirmer 1 test scores, higher OSDI scores, and higher anticholinergic burden (74% with ABC ≥1) compared with individuals in the control group (P =.01 for all), the report shows.

In individuals at risk of DED, increased awareness of anticholinergic burden may allow for earlier targeted health interventions.

Anticholinergic burden demonstrated statistically significant positive correlations with age (r, 0.21; P =.03) and OSDI score (r, 0.22; P =.02), while showing a negative correlation with Schirmer test scores (r, −0.46; P =.01). 

Each 1-point increase in anticholinergic burden resulted in an approximately 3 fold increase in DED risk (odds ratio [OR], 2.97; 95% CI, 1.22–7.24; P =.02) after adjusting for confounding factors, according to the report.

“This study revealed that the cooccurrence of DED and exposure to anticholinergic drugs is not uncommon among adults,” according to the researchers. “In individuals at risk of DED, increased awareness of anticholinergic burden may allow for earlier targeted health interventions.”

Study limitations include an inability to determine the frequency of anticholinergic drug use among the cohort and the small sample size used in the regression analysis, which may have affected statistical significance.


Katipoğlu Z, Abay RN. The relationship between dry eye disease and anticholinergic burdenEye (Lond). Published online February 9, 2023. doi:10.1038/s41433-023-02442-x