“Dry eye” is considered a disease of the ocular surface and the majority of treatment is geared towards lubrication and eyelid hygiene to reduce inflammation and re-establish tear film homeostasis. But what happens when treatment fails or patients present with symptoms of dry and severe ocular surface pain without signs of ocular surface dysfunction? As primary eyecare providers we often think to treat the eye first, but what exactly are you treating if there are no signs of ocular surface disease? What if the symptoms of dry eye is secondary to a neurological dysfunction in pain perception or an underlying neurologic disease? This course reviews the neurosensory pathways of dry eye and the pathophysiological overlap with neuropathic pain and photophobia. Emphasis will be placed on differentiating primary dry eye disease from secondary dry eye disease and neuropathic pain to aid in appropriate diagnosis, triage, referral, and treatment. Neurologic and psychiatric disorders reviewed will include chronic pain syndrome, TBI, chronic migraine, fibromyalgia, Parkinsons disease, anxiety and depression.