What are the treatment options for dry eyes?

Treatment Options for Dry Eyes

Artificial tears are the first-line treatment for dry eye disease, with preservative-free formulations recommended for frequent use (more than four times daily) to minimize ocular surface toxicity. 1

Stepwise Approach Based on Severity

Mild Dry Eye

1. Environmental and behavioral modifications:

   • Address exacerbating factors: antihistamine/diuretic use, cigarette smoking, low humidity environments, air drafts
   • Humidify ambient air
   • Use side shields on spectacles
   • Lower computer screen below eye level to decrease lid aperture
   • Schedule regular breaks during screen time
   • Practice conscious blinking 1

2. Artificial tears:

   • Start with preserved formulations if using less than 4 times daily
   • Options include emulsions, gels, and ointments
   • Thicker agents (gels, ointments) provide longer-lasting effect but may blur vision
   • Switch to preservative-free formulations if using more than 4 times daily 1

3. Treat contributing factors:

   • Address blepharitis or meibomianitis if present
   • Correct eyelid abnormalities (trichiasis, lagophthalmos, entropion/ectropion) 1

Moderate Dry Eye

Continue mild dry eye treatments plus:

1. Anti-inflammatory therapies:

   • Topical cyclosporine 0.05% - Instill one drop twice daily in each eye approximately 12 hours apart 2
     • Mechanism: Prevents T-cell activation and inflammatory cytokine production
     • Efficacy: 15% of patients showed significant improvement in tear production vs. 5% with vehicle
     • Can be used with artificial tears (allow 15-minute interval between products)
     • Side effects: Ocular burning (17% of patients)
     • May be effective in 67-74% of patients regardless of dry eye severity 1

2. Topical lifitegrast 5%:

   • LFA-1 antagonist that reduces inflammation
   • FDA approved in 2016 1

3. Punctal occlusion:

   • Temporary plugs to conserve tears
   • Consider after failure of artificial tears 1

4. Short-term topical corticosteroids:

   • For acute inflammatory flares
   • Limited duration (2-4 weeks) to avoid complications 1

Severe Dry Eye

Continue previous treatments plus:

1. Permanent punctal occlusion:

   • Thermal or laser cautery
   • Trial temporary plugs first to assess for epiphora 1

2. Autologous serum eye drops:

   • For severe cases not responding to other therapies 1

3. Oral medications:

   • Cholinergic agonists (cevimeline, pilocarpine)
   • Particularly useful in Sjögren's syndrome 1

4. Specialized contact lenses:

   • Rigid gas-permeable scleral lenses
   • Soft contact lenses (with caution due to infection risk) 1

5. Surgical approaches:

   • Limited tarsorrhaphy
   • Amniotic membrane grafts
   • Salivary gland transplantation 1

Special Considerations

Sjögren's Syndrome

• For patients with no salivary output, saliva substitutes should be considered 1
• Muscarinic agonists (pilocarpine, cevimeline) may be considered for patients with moderate glandular dysfunction 1

Common Pitfalls

1. Overuse of preserved artificial tears - Can cause toxicity and worsen symptoms; switch to preservative-free formulations when using more than 4 times daily 1

2. Inadequate treatment of underlying conditions - Blepharitis, meibomian gland dysfunction, and eyelid abnormalities must be addressed for optimal outcomes 1

3. Poor patient compliance - The effectiveness of artificial tears depends on proper application and frequency; patients may need guidance on proper instillation techniques 3

4. One-size-fits-all approach - Different formulations may work better for specific tear deficiencies:

   • Osmolarity-balanced tears for low tear volume
   • Lipisomal sprays for lipid layer deficiency 4

5. Failure to escalate therapy - If artificial tears alone are insufficient, anti-inflammatory treatments should be added rather than just increasing artificial tear frequency 1, 3

The management of dry eye requires a systematic approach based on severity, with artificial tears forming the foundation of treatment across all severity levels. As symptoms persist or worsen, additional therapies targeting inflammation and tear conservation should be incorporated.