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February 6, 2002

Dry Eye Syndrome in Postmenopausal Women—Reply

Author Affiliations

Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2002

JAMA. 2002;287(5):585-586. doi:10.1001/jama.287.5.583

In Reply: We agree with Dr Peterson and colleagues that ocular rosacea is a frequent and important, and perhaps underappreciated, cause of dry eye syndrome, particularly in certain ethnic groups. However, the proportion of dry eye cases attributable to this disorder is only speculative and solid epidemiological data on the prevalence of rosacea are lacking.1 The 30% prevalence of rosacea among postmenopausal women cited by Peterson et al is much higher than other estimates, which are in the range of 3% to 5%,2 and is derived from the clinical observations of a single dermatologist.1 In any event, even if rosacea were common, this would not be sufficient for rosacea to have confounded the association we observed between HRT and dry eye syndrome. For rosacea to confound the relationship, postmenopausal women with rosacea would have had to have been more likely to have received HRT, and specifically more likely to have taken estrogen alone, as we found a higher risk of dry eye syndrome among women using estrogen only than among those using estrogen plus progesterone/progestin. However, we are not aware of any evidence to suggest that women with ocular rosacea are more likely to use HRT in general or, more specifically, to use estrogen alone compared with women without this condition. It is consequently unlikely, from a statistical point of view, that ocular rosacea is an important confounder of the increased risk of dry eye syndrome we observed among women who received HRT. More at issue, perhaps, is whether the effect of HRT on dry eye syndrome, if causal, is differential with regard to certain subgroups of patients with dry eye syndrome, such as those due to ocular rosacea. Since one potential mechanism through which estrogen might influence the development of dry eye is via alterations of the secretions of the meibomian glands,3 which are also affected in ocular rosacea, we think that this is an important issue that will require further study.

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