What are the treatment options for dry eyes?

Treatment Options for Dry Eyes

The first-line treatment for dry eyes is artificial tears, with preservative-free formulations recommended for frequent use (more than 4 times daily) to prevent preservative-induced toxicity. 1, 2

Step-by-Step Treatment Algorithm

Step 1: First-Line Treatment and Environmental Modifications

• Artificial tears: Start with artificial tears containing methylcellulose or hyaluronate at least twice daily, increasing frequency as needed up to hourly application 1
  • Use preservative-free formulations when applying more than 4 times daily 1, 2
  • For nighttime use, consider thicker ophthalmic ointments before bedtime 1
• Environmental modifications:
  • Humidify ambient air
  • Avoid air drafts (use side shields on spectacles)
  • Lower computer screen below eye level to decrease lid aperture
  • Schedule regular breaks during computer use
  • Practice conscious blinking
  • Eliminate cigarette smoking and second-hand smoke exposure 1

Step 2: For Moderate Dry Eye (If Step 1 is Inadequate)

• Anti-inflammatory therapy:
  • Topical cyclosporine 0.05% twice daily in each eye, approximately 12 hours apart 3
    • Can be used concomitantly with artificial tears (allow 15-minute interval between products)
    • Has shown success rates of 72-74% in moderate dry eye 1
  • Topical lifitegrast ophthalmic solution 5% 2
  • Short-term topical corticosteroids (2-4 weeks) 1
• Tear conservation:
  • Punctal occlusion (temporary or permanent) 1, 2
  • Moisture chamber spectacles/goggles 1

Step 3: For Severe or Refractory Dry Eye

• Advanced therapies:
  • Autologous serum eye drops 1, 2
  • In-office physical heating and expression of meibomian glands 1
  • Oral muscarinic agonists (pilocarpine, cevimeline) for patients with moderate glandular dysfunction 1
  • Amniotic membrane grafts 1
  • Surgical approaches (tarsorrhaphy, salivary gland transplantation) 1

Special Considerations

Artificial Tear Selection

• For mild symptoms: Standard artificial tears with preservatives (if used ≤4 times daily) 1, 2
• For moderate to severe symptoms: Preservative-free formulations 1, 2
• For meibomian gland dysfunction: Consider lipid-containing artificial tears 2, 4
• For nighttime use: Thicker formulations (gels, ointments) provide longer-lasting relief but may cause temporary blurred vision 2

Addressing Contributing Factors

• Treat underlying blepharitis or meibomianitis 1
• Correct eyelid abnormalities (trichiasis, lagophthalmos, entropion/ectropion) 1
• Review and potentially modify medications that may exacerbate dry eye (antihistamines, diuretics) 1

Common Pitfalls to Avoid

1. Overuse of preserved artificial tears - can cause preservative-induced toxicity when used more than 4 times daily 1, 2
2. Failure to address environmental factors - environmental modifications are essential components of treatment 1
3. Inadequate lid hygiene - morning lid hygiene is particularly important when using ointments at night to prevent blepharitis 1
4. Monotherapy approach - combination therapy with artificial tears and anti-inflammatory agents is often needed for moderate to severe cases 2
5. Delayed escalation of therapy - if first-line treatments are inadequate, promptly move to next treatment steps rather than continuing ineffective therapy 1

Artificial tears remain the cornerstone of dry eye treatment, with a recent Cochrane review confirming they are safe and effective, though there is limited evidence that any specific formulation is superior to others 5. The treatment approach should follow a stepwise progression based on symptom severity and response to therapy.