Photo courtesy of Dr. Ann M. Hoscheit
A closer look at how hormonal and systemic health can shape dry eye care and practice growth
By Ann M. Hoscheit, OD, FAAO, FAARM, CHC
July 31, 2026
Quick summary:
- Ocular surface issues like dry eye are often linked to systemic factors, requiring a pivot from routine exams to dedicated medical evaluations and questionnaires.
- Routine eye exams don’t allow enough time for complex root causes; patients with persistent symptoms should return for dedicated medical evaluations and targeted questionnaires.
- Basic metrics like normal TSH levels don’t rule out systemic issues—ODs should look for broader symptom patterns and advocate for thorough panel testing when needed.
- Effective treatment requires addressing individual lifestyle factors (sleep, nutrition, hydration) and collaborating closely with primary care doctors, OB-GYNs, and endocrinologists.
- Connecting systemic health dots builds deep patient trust and word-of-mouth referrals, serving as both superior patient care and a key business differentiator.
Hormone-related eye complaints rarely show up in isolation. A patient may present with dry eye, fluctuating vision, ocular discomfort or simply say, “My eyes just don’t feel right.” But there have never been just two eyeballs sitting in my chair—the whole person is sitting there.
That means looking beyond the ocular surface and listening for clues involving nutrition, gastrointestinal health, stress/cortisol, insulin resistance, thyroid function and sex hormones (e.g. perimenopause, menopause, andropause). Learning to connect those dots changed my clinical outcomes, shaped the way I built my practice and became an important focus of my teaching, writing and consulting.
Optometrists do not need to become endocrinologists to make a meaningful difference. We do need to recognize patterns, ask better questions and know when to pivot from a routine examination to a more focused diagnostic conversation.
START WITH THE SYMPTOM PATTERN
Hormonal influences may appear through familiar eye complaints, but the important clue is often the context. New or worsening dry eye, fluctuating vision or ocular surface disease that fails to respond as expected should prompt questions about hormonal health. Similar considerations may apply to younger women taking oral contraceptives, patients diagnosed with PCOS and women undergoing fertility treatment or experiencing pregnancy-related hormonal shifts.
In men, dry eye symptoms, sometimes described as contact-lens discomfort, burning or excessive watering, may occur alongside age-related androgen decline and broader metabolic concerns. A man in his 40s or 50s with newly diagnosed diabetes, central weight gain, fatigue and ocular surface symptoms may appreciate a clinician who is willing to consider the full picture. The optometrist’s role is not to diagnose low testosterone from the examination chair but to recognize the pattern and co-manage the patient care.
DON’T LOOK AT HORMONES IN ISOLATION
Hormones should never be considered in isolation. A useful way to think about hormonal health is as a hierarchy. Lifestyle, nutrition, GI health, movement and sleep form the foundation. Insulin regulation, the stress response and thyroid function occupy the middle. Sex hormones sit nearer the top. Each level influences the others.
The point is not that every symptom can be placed neatly into one layer of a pyramid. Rather, it is a reminder that chronic GI dysfunction, insulin resistance, inadequate sleep, sustained stress and systemic inflammation can influence the hormonal cascade, including what appears on the ocular surface. Ocular inflammation is frequently just the tip of the iceberg.
Why does this matter? When the focus remains exclusively on the ocular surface, important underlying contributors may be missed. A routine examination is not the setting in which to solve ocular surface disease and its underlying causes. It is, however, the place to recognize when a patient should return for a focused consultation or be co-managed with another provider.
KNOW WHEN TO PIVOT—AND WHAT TO TEST
Optometrists already understand the concept of diagnostic escalation. When elevated intraocular pressure is discovered during an annual examination, a complete glaucoma evaluation is not squeezed into the remaining minutes of the visit. The patient returns for appropriate testing, such as gonioscopy, pachymetry, OCT and visual-field testing.
The same principle applies to ocular surface disease. When the patient’s chief complaint suggests ocular surface disease, the patient should return for a dedicated medical visit and thorough diagnostic process.
THYROID TESTING IS MORE THAN TSH
Thyroid function is an important example. In many conventional evaluations, testing begins, and sometimes ends, with TSH (thyroid stimulating hormone). TSH is a useful starting point, but a result within the laboratory reference range should not automatically close the discussion when the patient continues to experience a cluster of symptoms, such as brittle nails, hair loss, cold intolerance, constipation, difficulty managing weight and worsening dry eye.
Persistent symptoms may justify a more complete thyroid evaluation by the patient’s managing clinician. Depending upon the history, that may include free T4, selected T3 testing and thyroid antibodies (TPO and Thyroglobin), along with consideration of nutrients important to thyroid physiology, such as vitamin D, magnesium and selenium.
The message for optometrists is to remain curious. When the ocular findings, systemic symptoms and initial laboratory results do not tell a coherent story, turn on your inner clinical sleuth and help the patient pursue the next appropriate step.
WHAT I ASK IN THE EXAM ROOM
A thorough history, thoughtful diagnostic process and comprehensive treatment plan require adequate time. Patients with suspected ocular surface disease are therefore scheduled for a dedicated medical consultation and asked to complete an Extended History for Ocular Surface Disease report before the visit.
The questionnaire addresses current symptoms and their effect on daily life; previous treatments, both successful and unsuccessful; systemic symptoms such as GI concerns, joint pain, dry mouth and dry nose; hormone-related symptoms and relevant medications; aesthetic procedures including surgery, lash extensions and injectables; nutritional supplements; and lifestyle factors such as sleep, hydration, caffeine intake, environmental exposure and CPAP use.
Within a minute or two of reviewing that information, an astute clinician can often identify several pieces of “low-hanging fruit” that can be addressed immediately while guiding the more advanced ocular-surface evaluation.
The questions themselves can remain simple and conversational. One of my favorites is: “Your eyes aren’t in my chair alone. Have you noticed any other changes—such as disrupted sleep, hot flashes, fatigue or another health change—that began around the same time?”
We are fortunate to have a plethora of advanced ocular surface treatments available however, for optimal success, it is critical that every treatment plan address modifiable factors such as contact-lens wear, environmental exposure, sleep, hydration, nutrition and other modifiable contributors. It’s never fun to back-track if we’ve missed these.
We want to do our best to prescribe individualized treatment plans rather than cookie-cutter plans—those are a dime-a-dozen. For instance, a patient with hypertension, kidney disease or heart failure for example, may require very different hydration or electrolyte guidance than an otherwise healthy patient.
Nutritional recommendations may include an anti-inflammatory eating plan (e.g. Mediterranean-style eating pattern) while also prescribing a therapeutic dose of triglyceride omega-3 fatty acids.
HORMONES, CATARACTS, GLAUCOMA AND METABOLIC DISEASE
Hormones are not the answer to every ocular condition, but hormonal and metabolic health are intimately linked to ocular health. Research continues to examine relationships among sex hormones, intraocular pressure, ocular blood flow, retinal ganglion-cell health, cataract development and metabolic eye disease. Glucose regulation remains important in cataract and retinal disease, while structural and functional testing remain central to glaucoma care. Hormonal history is one additional piece of a much larger clinical picture.
MAKE THE REFERRAL PATH EASY
When a possible hormonal or systemic contributor is identified, create a clear pathway for testing and co-management. This may include selected in-office testing or referral to a like-minded primary-care physician, OB-GYN, endocrinologist or integrative-medicine provider.
Relationships matter. Identify clinicians in the community who are receptive to collaboration and make the referral easy to understand. A brief phone call of introduction is often helpful as well as follow-up written clear communication with your recommended diagnostic testing (be as specific as possible) and differential diagnosis.
WHY THIS MATTERS FOR PRACTICE GROWTH
This is a unique opportunity for optometrists who are curious, disciplined and willing to continue learning. Patients notice when a health care provider listens and connects the dots. They remember the doctor who asked about sleep, hormones, hydration, medication and inflammation rather than simply recommending another bottle of drops and moving on.
That experience builds loyalty, drives referrals from family and friends and differentiates a practice in a crowded market.
This is not a gimmick; it is a more comprehensive approach to medical eyecare. At a time when patients may wait weeks or months for primary or specialty care, optometrists can help identify concerns, educate patients and create an efficient pathway to the appropriate provider.
A broader culture of wellness can reinforce that philosophy. In our practice, that included wellness fairs, Walks with a Doc, in-office yoga, spring water, healthy snacks and an environment that encouraged both patients and staff to think more intentionally about health.
THE TAKEAWAY IS STRAIGHT FORWARD
When caring for a patient with ocular surface disease, remain curious. Hormones may not be the whole story, but they are often part of it. Ask better questions and patients will recognize something increasingly rare in health care: they have been heard.
That is good medicine and good business. In fact, we built our practice around this promise: You see, we listen. And when we listen, you see.
Read more on senior patient care here.
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Ann M. Hoscheit, OD, FAAO, FAARM, CHC, is an optometric physician, board-certified integrative medicine provider, practice founder and former owner, consultant and nationally recognized educator. In 2009, she was among the earliest optometrists to earn board certification in integrative medicine and began lecturing on women’s health and hormonal health in both women and men around 2010. She has spent much of her career helping optometrists connect ocular findings with systemic health while building clinically differentiated, patient-centered practices. She is the founder of EyeBridge Consulting Associates. To contact her: DrAnn@EyeBridgeConsulting.com |
