What are the best eye drops for treating dry eyes?

Best Eye Drops for Dry Eyes

For treating dry eyes, preservative-free artificial tears are recommended, especially when used more than four times daily, as they provide effective symptom relief without the risk of preservative-induced toxicity. 1, 2

Treatment Algorithm Based on Severity

Mild Dry Eye

• First-line treatment: Artificial tears 4 times daily 2
  • For infrequent use (≤4 times/day): Preserved artificial tears acceptable 1, 2
  • Environmental modifications: Humidify ambient air, avoid air drafts, reduce computer screen height 1
  • Lifestyle adjustments: Schedule regular breaks during computer use, practice conscious blinking 1

Moderate Dry Eye

• Increase frequency of artificial tears as needed (up to hourly application) 2
• Switch to preservative-free formulations when using >4 times daily 1, 2
• Consider thicker formulations (emulsions, gels, ointments) for longer-lasting effect 1
• Consider anti-inflammatory therapies as adjuncts:
  • Topical cyclosporine 0.05% 1
  • Lifitegrast ophthalmic solution 5% 1

Severe Dry Eye

• Preservative-free artificial tears at high frequency 1, 2
• Consider autologous serum eye drops 1
• Consider punctal occlusion (temporary or permanent) 1
• For filamentary keratitis: Consider mucolytic agents (N-acetylcysteine 10%) 1
• For refractory cases: Consider scleral lenses or amniotic membrane 1

Types of Artificial Tears

Key Considerations

• Preservative status: Preservative-free preferred for frequent use (>4 times/day) 1, 2
• Viscosity: Higher viscosity provides longer-lasting relief but may cause temporary blurred vision 1
• Composition: For meibomian gland dysfunction, consider lipid-containing formulations 1

Evidence on Specific Formulations

• Polyacrylic acid-based drops (0.2%) showed better symptom relief than polyvinyl alcohol-based drops (1.4%) in comparative studies 3
• Fixed dosing (four times daily) of polyethylene glycol/propylene glycol drops provided better symptom relief than as-needed dosing 4
• Most artificial tears have comparable efficacy, though study designs and reporting are inconsistent 1, 3

Important Caveats and Pitfalls

• Preservative toxicity: Benzalkonium chloride (BAK) can decrease goblet cell count by 37.5% and worsen symptoms when used frequently 5, 6
• Undertreatment: Using artificial tears less frequently than needed may lead to inadequate symptom control 4
• Environmental factors: Failure to address contributing factors (air conditioning, computer use, smoking) may limit treatment success 1
• Associated conditions: Untreated blepharitis or meibomian gland dysfunction can perpetuate dry eye symptoms despite adequate lubrication 1

Special Considerations

• For nighttime use: Consider ointments or gels for longer-lasting effect 1
• For contact lens wearers: Use compatible preservative-free formulations 6
• For autoimmune conditions (e.g., Sjögren's syndrome): Higher frequency of preservative-free drops typically required 2
• For severe cases: Consider combination therapy with anti-inflammatory agents and artificial tears 1

Remember that artificial tears treat symptoms but may not address underlying inflammation. For moderate to severe cases, anti-inflammatory therapies may be necessary alongside artificial tears for optimal management 1.