What are the treatment options for dry eyes, including medications like Restasis (cyclosporine) and Xiidra (lifitegrast)?

Treatment Options for Dry Eyes

For dry eye disease, a stepwise approach starting with artificial tears for mild cases and progressing to anti-inflammatory medications like cyclosporine (Restasis) and lifitegrast (Xiidra) for moderate to severe cases is recommended based on disease severity.

First-Line Treatment for Mild Dry Eye

• Begin with environmental and behavioral modifications to address exacerbating factors:

  • Eliminate exposure to cigarette smoke which adversely affects the lipid layer of the tear film 1
  • Humidify ambient air and avoid air drafts by using side shields on spectacles 1
  • Lower computer screens below eye level to decrease eyelid aperture and schedule regular breaks 1
  • Increase conscious blinking during computer use and reading activities 1

• Initiate artificial tears as primary treatment:

  • Polymeric-based lubricants (methylcellulose-based or hyaluronic acid-based) are the mainstay of treatment 2
  • Use preservative-free formulations when applying more than four times daily 1, 2
  • Consider different formulations based on time of day:
    • Liquid drops for daytime use
    • Gels for longer-lasting effect
    • Ointments for overnight use 2

• Address contributing ocular factors:

  • Treat concurrent blepharitis or meibomian gland dysfunction 1
  • Correct eyelid abnormalities (trichiasis, lagophthalmos, entropion/ectropion) 1

Second-Line Treatment for Moderate Dry Eye

• When artificial tears provide insufficient relief, add anti-inflammatory therapies:

• Cyclosporine ophthalmic solution 0.05% (Restasis):

  • Mechanism: Prevents T-cell activation and inflammatory cytokine production 1
  • Dosing: Twice daily application 1
  • Efficacy: Demonstrated success in 74%, 72%, and 67% of patients with mild, moderate, and severe dry eye, respectively 1, 3
  • Common side effect: Ocular burning in approximately 17% of patients 1
  • Long-term use: May be reduced to once daily after one year of twice-daily therapy 1
  • Potential disease-modifying effects: May increase tear production and goblet cell density 1

• Lifitegrast ophthalmic solution 5% (Xiidra):

  • FDA-approved for treatment of signs and symptoms of dry eye disease 4
  • Mechanism: Blocks interaction between LFA-1 and ICAM-1, preventing T-cell activation 1, 5
  • Efficacy: Improves both signs (corneal and conjunctival staining) and symptoms (eye dryness and ocular discomfort) over 3 months 1, 5
  • Safety profile: Generally well-tolerated with long-term use up to 12 months 1, 5

• Short-term topical corticosteroids:

  • Can decrease ocular irritation symptoms and corneal fluorescein staining 1
  • Should be limited to short-term use (2-4 weeks) to avoid complications 1, 2
  • Particularly useful as initial therapy before starting cyclosporine 1

Advanced Treatments for Severe Dry Eye

• Punctal occlusion for tear retention:

  • Consider after optimizing topical therapy 1
  • Options include:
    • Temporary silicone plugs (useful for trial occlusion) 1
    • Permanent thermal or laser cautery (less reversible) 1
  • Use a stepwise approach, occluding no more than one punctum per eye at each treatment session 1

• Autologous serum eye drops:

  • Beneficial for severe dry eye, particularly in Sjögren's syndrome 1
  • Improves ocular irritation symptoms and corneal/conjunctival staining 1, 2

• Oral medications for severe cases:

  • Cevimeline or pilocarpine (5mg four times daily) for patients with Sjögren's syndrome 1
  • These cholinergic agonists stimulate tear production 1
  • Side effects include excessive sweating (in over 40% of patients with pilocarpine) 1

• Specialized contact lenses:

  • Rigid gas-permeable scleral lenses for severe dry eye 1
  • Soft contact lenses may provide symptomatic relief in selected cases 1
  • Note increased risk of infection, especially with extended wear 1

Common Pitfalls to Avoid

• Overuse of preserved artificial tears can cause toxicity to the ocular surface 2
• Extended use of topical corticosteroids can lead to complications including infections and increased intraocular pressure 2
• Neglecting to address underlying conditions like blepharitis or meibomian gland dysfunction 2
• Inadequate treatment of severe dry eye can lead to corneal ulceration and vision loss 2
• Failure to recognize when to advance therapy from artificial tears to anti-inflammatory agents in moderate to severe disease 1