What are the best eye drops for treating dry eyes?

Best Eye Drops for Dry Eyes

Preservative-free artificial tears containing methylcellulose or hyaluronate should be used as first-line therapy for dry eye syndrome, applied at least twice daily and increased to hourly as needed based on symptom severity. 1

First-Line Treatment Options

Preservative-Free Artificial Tears

• Preservative-free formulations are preferred over preserved ones, especially for moderate to severe dry eye or frequent use
• Methylcellulose or hyaluronate-based tears provide better symptom relief and corneal healing 1
• Fixed dosing (four times daily) may provide better symptomatic relief than as-needed use 2
• Preservative-free tears have been shown to improve goblet cell count by up to 40% in research studies 3

Types of Artificial Tears Based on Ingredients

Artificial tears can be categorized into four main groups:

1. Cellulose derivatives (methylcellulose, carboxymethylcellulose)
2. Hyaluronic acid/sodium hyaluronate formulations
3. Polyvinyl alcohol/povidone based products
4. Oil-based emulsions for lipid layer deficiency 4

Second-Line Treatment Options

For moderate to severe dry eye with significant inflammation:

Prescription Anti-inflammatory Medications

• Cyclosporine ophthalmic emulsion 0.05% (Restasis): Instill one drop twice daily in each eye approximately 12 hours apart 1, 5
• Lifitegrast 5% ophthalmic solution (Xiidra): FDA-approved for moderate to severe dry eye 1

Corticosteroid Eye Drops

• Can be used for acute inflammatory signs
• Require monitoring for increased intraocular pressure and infection risk
• Preservative-free formulations show better outcomes in patients with pre-existing dry eye 1, 6

Advanced Treatment Options for Severe Cases

For refractory cases not responding to conventional therapy:

• Autologous serum eye drops
• Amniotic membrane grafts
• Rigid gas-permeable scleral lenses (though limited by fitting difficulties and cost)
• Oral cholinergic agonists like cevimeline or pilocarpine (especially for Sjögren's syndrome) 1

Treatment Selection Algorithm

1. For mild dry eye:

   • Start with preservative-free artificial tears containing methylcellulose or hyaluronate
   • Use four times daily (fixed schedule) rather than as-needed for better outcomes 2

2. For moderate dry eye with lipid deficiency:

   • Consider lipisomal sprays or oil-based emulsions 7

3. For low tear volume:

   • Osmolarity-balanced artificial tears are preferred 7

4. For moderate to severe dry eye with inflammation:

   • Add cyclosporine 0.05% or lifitegrast 5% to artificial tear regimen 1

5. For severe or refractory cases:

   • Consider short-term topical steroids followed by maintenance with cyclosporine
   • Evaluate for underlying systemic conditions (especially Sjögren's syndrome) 1

Important Considerations and Pitfalls

• Preservatives: Avoid benzalkonium chloride, which can decrease goblet cell count by 37.5% and worsen dry eye symptoms with long-term use 3
• Environmental modifications: Humidify ambient air, avoid air drafts, and practice conscious blinking 1
• Medication review: Identify and modify contributing medications like antihistamines and diuretics 1
• Contact lens wearers: Require more aggressive therapy; consider preservative-free options 1
• Underlying conditions: Consider serological work-up for Sjögren's syndrome if dry eye is severe or persistent 1

The evidence strongly supports that preservative-free artificial tears should be the cornerstone of dry eye treatment, with fixed dosing schedules providing better outcomes than as-needed use. For cases with significant inflammation, prescription anti-inflammatory medications should be added to the regimen.