Welcome to the third feature article in Insight Media’s Decoding Dry Eye Practice Success series. In case you missed it, read the first two installments, which focus on effectively uncovering and diagnosing DED as well as starting with the basics.
This is an exciting time for dry eye treatment, with more options than ever before. But with a growing number of therapies available, how do we determine which options are right for each patient?
While it is not possible to cover every therapy within the scope of this article, this overview offers a helpful starting point for continued learning as we work to provide individualized care for each patient.
Start Simple
Dry eye disease is multifactorial, and our treatment strategies should reflect that complexity. Dry eye treatment may seem complicated, but it starts simple: prioritize sleep, hydration, regular breaks from digital devices, daily eyelid hygiene, and daily eye lubrication. I tell patients, “Just like you brush your teeth every day, you need to clean your eyelids every day.”
Also, I use the analogy that artificial tears are like hand lotion. If you use them once in the morning and once in the evening, you get the most benefit. Use them regularly, not just when your eyes already feel dry.
Tailor Treatment
Effective management depends on accurately identifying the specific contributors to the patient’s dry eye disease. Determining factors such as eyelid disease, evaporation, inflammation, meibomian gland dysfunction, lifestyle or environmental factors, and medications allows us to target the treatment accordingly. Once we know the underlying cause of dry eye disease, treatment becomes more customized, which often includes use of concomitant treatments.
A useful resource to start is the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) III Management and Therapy publication. After we determine the primary cause or causes of ocular surface disease, we can initiate treatment to address the cause. For example, I may prescribe medications that reduce evaporation, stimulate natural tear production, or treat a specific condition, such as Demodex blepharitis or neurotrophic keratitis.
Eyelid hygiene, mechanical debridement, and topical or oral antibiotics may be appropriate as well depending on the clinical presentation. Also, Demodex blepharitis should be specifically identified, especially when collarettes are present. Lotilaner provides a targeted treatment option that has changed how we approach this common condition.
Once we know the underlying cause of dry eye disease, treatment becomes more customized, which often includes use of concomitant treatments.
Evaluate Evaporation + More
For those with increased tear evaporation, new therapies allow us to address evaporation more directly.
Perfluorohexyloctane forms a monolayer at the air-tear interface, helping reduce tear evaporation. Punctal occlusion, including cross-linked hyaluronic acid canalicular fillers designed for extended tear conservation, may also increase tear retention.
Additional options include low-dose corticosteroids, lifitegrast, cyclosporine, including newer cyclosporine formulations using novel carrier molecules, amniotic membranes, serum tears, platelet-rich plasma and scleral lenses. Neurostimulation, by both therapeutic and mechanical approaches, has further expanded our ability to activate the lacrimal functional unit and stimulate the patient’s own tear production. TRPM8 receptors may offer additional opportunities to modulate tear production and ocular surface sensation.
Options to address meibomian gland function directly include heat-based treatments, thermal pulsation with expression, intense pulsed light, and radiofrequency. These options move treatment toward an interventional approach rather than relying exclusively on home therapy.
Consider Environment and Lifestyle
Environmental factors are also important. Overhead fans, CPAP use, inadequate hydration, sleep disorders, systemic medications, allergies, and antihistamines all contribute to ocular surface disease. We can also incorporate nutrition, exercise, and omega fatty acid supplementation. A great resource to learn more is the TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface.
Thanks to the available treatment options, dry eye management has become increasingly individualized, targeted, and interventional.
About the Author: Melissa Barnett, OD, FAAO, FSLS, FBLCA, ACC, is a Doctor of Optometry, podcast host, and founding board member of the Intrepid Eye Society. She is also an ICF Associate Certified Coach and the founder of Alpine Blue Coaching.