Study Finds Collarettes Common in Moderate-to-Severe Dry Eye but Don't Always Progress
Lid margin collarettes are frequently observed in patients with moderate-to-severe dry eye disease (DED), but most do not worsen over time and show no association with dry eye symptoms, according to new research analysing data from the Dry Eye Assessment and Management (DREAM) study.
The secondary analysis, led by Alexander E. Azar from Case Western Reserve University School of Medicine in Cleveland, Ohio, examined 535 patients enrolled in the original DREAM trial—a multi-centre, double-blinded study evaluating omega-3 supplementation versus olive oil placebo over 12 months.
At baseline assessment, researchers found collarettes were present in 35% of eyes examined. Of these, 28% showed mild presentation (1-5 collarettes), whilst 7% demonstrated moderate severity (6-20 collarettes with fragments). Notably, no eyes presented with severe or very severe collarettes at the study's commencement, though small numbers were recorded at the 6- and 12-month follow-ups.
The researchers graded collarette presence on a five-point scale, ranging from normal (zero collarettes) through to very severe (over 40 collarettes with more than three clumps).
Whilst eyes with collarettes exhibited more severe DED signs overall—reflected in higher composite severity scores—the relationship wasn't straightforward across all clinical measures.
Collarette presence correlated with worse outcomes for eyelid erythema, with 18.6% of affected eyes showing moderate or severe inflammation compared to 12.2% without collarettes. Other associated signs included reduced tear break-up time, lower Schirmer test scores, and increased corneal staining.
However, the study found no significant link between collarettes and conjunctival staining or meibomian gland dysfunction grade. Intriguingly, tear osmolarity readings were unexpectedly better in eyes with collarettes.
The researchers noted that whilst DED signs were more severe with collarette presence, "not all signs were linearly associated with greater collarette severity." Eyelid erythema, tear break-up time, MGD grade, and composite DED severity scores worsened with increasing collarette severity, whereas conjunctival staining, corneal staining, and Schirmer test results showed no significant association.
Despite the clinical sign associations, researchers found no link between collarettes and patient-reported dry eye symptoms as measured by the Ocular Surface Disease Index and ocular discomfort assessments.
The analysis revealed a significant association between collarettes and rosacea. Additionally, White and non-Hispanic patients with moderate-to-severe DED were more likely to present with collarettes, though the authors cautioned that further research is needed to understand whether this reflects skin phototype, genetics, or other confounding factors.
The researchers acknowledged that the study's limitations included a lack of detailed characterisation of collarette type, which may warrant investigation in future research.
The findings have been published in Eye and offer eyecare practitioners additional insight into the clinical presentation of collarettes in the DED patient population, though their prognostic significance remains uncertain.
References:
- Azar AE, Haddad EN, Augello PA. Association between lid margin collarettes and dry eye disease severity in the Dry Eye Assessment and Management (DREAM) study. Assessment and Management (DREAM) study. Eye. 2025. https://doi.org/10.1038/s41433-025-04105-5
- NCT02128763. Dry Eye Assessment and Management Study (DREAM). University of Pennsylvania, clinicaltrials.gov. Last updated July 19, 2022. Accessed November 26, 2025. https://clinicaltrials.gov/study/NCT02128763
