Treatment for Dry Eyes
For dry eye disease, treatment should follow a stepwise approach starting with artificial tears for mild cases, advancing to prescription medications like cyclosporine 0.05% or lifitegrast 5% for moderate to severe cases, and considering advanced therapies for refractory disease. 1
First-Line Treatment
Artificial Tears
- For mild symptoms: Preserved artificial tears (≤4 times/day) 1
- For moderate symptoms: Preservative-free artificial tears (>4 times/day) 1
- Important considerations:
Environmental and Behavioral Modifications
- Humidify ambient air
- Avoid air drafts
- Practice conscious blinking
- Lower computer screens below eye level to decrease lid aperture 1
- Identify and modify/eliminate contributing medications (antihistamines, diuretics) 1
Second-Line Treatment (Moderate to Severe Dry Eye)
Anti-inflammatory Therapy
Cyclosporine ophthalmic emulsion 0.05% (Restasis) 1, 3
- Mechanism: Inhibits T-cell activation and inflammatory cytokine production
- Dosage: One drop twice daily in each eye, approximately 12 hours apart 3
- Efficacy: 72-74% success rate in moderate dry eye
- Side effects: Ocular burning in 17% of patients
- Can be used concomitantly with artificial tears (allow 15-minute interval between products) 3
Lifitegrast ophthalmic solution 5% (Xiidra) 1
- Mechanism: Blocks interaction between LFA-1 and ICAM-1
- FDA-approved for both signs and symptoms of dry eye
- Benefits: Improves corneal/conjunctival staining and reduces symptoms
Short-term topical corticosteroids 1
- Preservative-free dexamethasone 0.1% for up to 8 weeks during acute flares
- Duration: 2-4 weeks for acute inflammatory signs
- Caution: Monitor for increased intraocular pressure and infection risk
Advanced Therapies (Severe or Refractory Cases)
Punctal Occlusion
- Temporary punctal plugs (silicone or collagen) as a trial before permanent occlusion 1
Specialized Topical Treatments
Autologous serum eye drops 1
- Contain factors that promote ocular surface renewal
- Recommended for severe dry eye refractory to conventional therapy
Combination of tacrolimus ointment and cyclosporine drops for treatment-resistant disease 1
Systemic Therapy
- Oral cholinergic agonists (cevimeline, pilocarpine) for Sjögren's syndrome 1
- Biologic therapy (rituximab) for severe and refractory cases 1
Mechanical Interventions
- Rigid gas-permeable scleral lenses
- Amniotic membrane grafts
- Surgical approaches (tarsorrhaphy, salivary gland transplantation) 1
Special Considerations
Addressing Underlying Conditions
- Treat blepharitis, meibomianitis, or eyelid abnormalities 1
- Correct eyelid abnormalities (trichiasis, lagophthalmos, entropion/ectropion) 1
Filamentary Keratitis
- Debride filaments with moistened cotton-tip applicator
- Apply topical mucolytic agents (N-acetylcysteine 10%) 1
Inflammatory Component
- 40-65% of symptomatic dry eye patients have significant inflammation requiring anti-inflammatory treatment 1
- Consider Sjögren's syndrome with serological work-up if dry eye is severe or persistent 1
Contact Lens Wearers
- Higher risk for complications
- May need more aggressive therapy 1
Monitoring and Follow-up
- Regular ophthalmological assessment to monitor:
- Corneal inflammation and thinning
- Intraocular pressure
- Visual acuity
- Tear film stability 1
- Baseline retinal nerve fiber layer optical coherence tomography for patients on prolonged corticosteroid therapy 1
Common Pitfalls to Avoid
- Neglecting underlying inflammation can lead to suboptimal outcomes 1
- Prolonged use of topical NSAIDs can lead to corneal-scleral melts, perforation, and ulceration 1
- Overuse of preserved artificial tears (>4 times/day) can cause toxicity 1
- Failure to address underlying conditions like blepharitis or meibomian gland dysfunction 1
- Inadequate follow-up for patients on long-term corticosteroid therapy 1