What is the best treatment for dry eyes?

Treatment for Dry Eyes: A Stepwise Approach

The best treatment for dry eyes follows a stepwise approach starting with artificial tears and environmental modifications for mild cases, progressing to prescription anti-inflammatory medications for moderate cases, and advanced interventions for severe cases that don't respond to initial therapy. 1

Step 1: First-Line Treatments for Mild Dry Eye

Environmental and Lifestyle Modifications

• Modify local environment by increasing humidity and avoiding air drafts
• Lower computer screen below eye level to decrease eyelid aperture
• Schedule regular breaks during computer use and practice conscious blinking
• Eliminate exacerbating factors:
  • Discontinue or minimize medications that worsen dry eye (antihistamines, diuretics)
  • Stop smoking and avoid second-hand smoke exposure
  • Use side shields on spectacles to reduce air movement

Ocular Lubricants

• Artificial tears are safe and effective for mild dry eye 1
• For occasional use: Preserved artificial tears are acceptable
• For frequent use (>4 times daily): Non-preserved formulations are recommended
• Options include:
  • Drops (lowest viscosity, minimal blurring)
  • Gels (medium viscosity, moderate duration)
  • Ointments (highest viscosity, longest duration, significant blurring)
• If meibomian gland dysfunction is present, use lipid-containing supplements

Lid Hygiene

• Regular warm compresses to improve meibomian gland function
• Gentle lid cleansing for anterior blepharitis
• Treat any contributing ocular conditions (blepharitis, trichiasis, lid malposition)

Step 2: Treatments for Moderate Dry Eye

When Step 1 treatments provide inadequate relief:

Anti-inflammatory Medications

• Topical cyclosporine 0.05% - Prevents T-cell activation and inflammatory cytokine production 1

  • Demonstrated success in 74%, 72%, and 67% of patients with mild, moderate, and severe dry eyes, respectively
  • May increase tear production in 15% of patients (vs. 5% with vehicle)
  • Can be disease-modifying with prolonged improvement of signs
  • Common side effect: burning sensation (17% of patients)

• Topical lifitegrast - LFA-1 antagonist that reduces inflammation

• Short-term topical corticosteroids - For acute flares (limited duration to avoid complications)

Tear Conservation

• Punctal plugs to block tear drainage
• Moisture chamber spectacles/goggles

Advanced Therapies

• In-office physical heating and expression of meibomian glands
• Tea tree oil treatment for Demodex mites (if present)
• Oral tetracycline or macrolide antibiotics for meibomianitis

Step 3: Treatments for Severe Dry Eye

For cases resistant to previous therapies:

• Longer duration topical corticosteroids (with careful monitoring)
• Amniotic membrane grafts
• Surgical punctal occlusion (cautery)
• Other surgical approaches (tarsorrhaphy, salivary gland transplantation)

Practical Considerations and Pitfalls

Common Pitfalls

1. Overuse of preserved artificial tears - Can cause toxicity and worsen symptoms when used >4 times daily
2. Inadequate treatment of underlying conditions - Always address blepharitis, meibomian gland dysfunction
3. Premature escalation of therapy - Allow sufficient time for first-line treatments to work
4. Inconsistent application - Patient adherence to regular treatment is essential

Treatment Selection Tips

• Match treatment intensity to disease severity
• Consider the underlying mechanism (aqueous deficiency vs. evaporative)
• For frequent computer users: emphasize blinking exercises and environmental modifications
• For contact lens wearers: use compatible lubricants and consider switching to daily disposable lenses

The evidence strongly supports a stepwise approach to dry eye management, with artificial tears and environmental modifications forming the foundation of treatment 1. For moderate to severe cases, anti-inflammatory therapies like cyclosporine have demonstrated effectiveness in improving both signs and symptoms 1, 2, though results can be variable between patients. The treatment plan should be adjusted based on clinical response, with progression to more advanced therapies when initial approaches prove insufficient.