A holistic dynamic concept on dry eye disease identifies several different interacting self‐enforcing vicious circles of disease progression

Purpose Dry Eye Disease ( DED ) is a complex alteration of the ocular surface. Typical are self‐enforcing mechanisms that drive the condition are termed ′Vicious Circles′ ( VC ). It is generally believed that ′ a vicious circle ′ occurs in DED that is driven by inflammation . Methods A NLM PubMed based review of the literature review was performed and pathogenetic mechanisms were analyzed according to patho‐physiology. Results This approach in DED indicates that Basic primary causative factors are (A) deficiency of tear SECRETION by the ocular secretory glands (aqueous lacrimal gland, oily Meibomian glands, single conjunctival goblet cell mucin glands) and (B) deficiency in FORMATION of a stable tear FILM by the eye lids & blinking. The two main pathologies are (1) tear film deficiency and (2) tissue damage. Several VC in DED were identified: One important VC is destruction of the surface epithelium by insufficient wetting due to a deficient tear film which, in turn, further reduces the tissue wettability and thus tear film stability. Surface destruction leads to induction of inflammatory pathways that drive VS for progression of disease. Since the destruction of the tissue also impairs the ocular glands, large VC of gland destruction (Pathological Carousels) occur wherein tissue destruction increasingly impairs gland secretion which, in turn, drives further surface destruction. Other VC are hidden in the gland pathology of Meibomian Gland Dysfunction ( MGD ) and Lacrimal Gland Dysfunction ( LGD ). Conclusions A holistic dynamic analysis of DED can identify, In contrast to present over‐simplified models, that Vicious Circles do not necessarily depend on inflammation and that there are in fact several, different, interacting vicious circles instead of just one. The relevant VC must be identified in the individual patient to allow an effective therapy.