What is the best treatment approach for chronic dry eye?

Treatment Approach for Chronic Dry Eye

The best treatment approach for chronic dry eye follows a stepwise algorithm based on disease severity, starting with environmental modifications and artificial tears for mild cases, advancing to anti-inflammatory agents like cyclosporine or lifitegrast for moderate cases, and considering punctal occlusion or autologous serum for severe cases. 1

Environmental and Behavioral Modifications (First Steps)

• 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 2, 1
• Lower computer screens below eye level to decrease eyelid aperture and schedule regular breaks 2, 1
• Increase conscious blinking during computer use and reading activities 1

First-Line Treatment for Mild Dry Eye

• Use artificial tears as initial therapy - most formulations have comparable efficacy 2, 1
  • Liquid drops for daytime use, gels and ointments for longer-lasting effect or overnight use 1
  • Polymeric-based lubricants (methylcellulose, hyaluronic acid) are mainstay treatments 1, 3
  • Combination formulations are more effective than single active ingredient artificial tears 3
  • Polyethylene glycol-containing tears may be more effective than carboxymethylcellulose or hydroxypropyl methylcellulose 3
• Switch to preservative-free formulations when using tears more than four times daily 2, 4
• Treat concurrent blepharitis or meibomian gland dysfunction if present 2, 1
• Correct eyelid abnormalities (trichiasis, lagophthalmos, entropion, ectropion) 2, 1

Second-Line Treatment for Moderate Dry Eye

• Add anti-inflammatory therapy when artificial tears provide insufficient relief:
  • Cyclosporine ophthalmic solution 0.05% (Restasis) - prevents T-cell activation and inflammatory cytokine production
    • Demonstrated success in 74%, 72%, and 67% of patients with mild, moderate, and severe dry eye, respectively 2, 1
    • Can reduce dosage to once daily after 1 year of twice-daily therapy 2
  • Lifitegrast ophthalmic solution 5% (Xiidra) - LFA-1 antagonist indicated for signs and symptoms of dry eye disease 5
    • Administered as one drop twice daily (approximately 12 hours apart) 5
    • Common side effects include instillation-site irritation, dysgeusia, and reduced visual acuity 5
  • Short-term topical corticosteroids (2-4 weeks maximum) for acute symptom relief 1
    • Caution: Extended use can lead to complications including infections and increased intraocular pressure 1

Advanced Treatments for Severe Dry Eye

• Punctal occlusion for tear retention after optimizing topical therapy 1
  • Begin with temporary silicone plugs before considering permanent thermal or laser cautery 1
• Autologous serum eye drops for severe dry eye, particularly in Sjögren's syndrome 1
• Oral medications (cevimeline or pilocarpine) to stimulate tear production in Sjögren's syndrome 1
• Specialized contact lenses (rigid gas-permeable scleral lenses) for severe cases 1

Treatment Selection Based on Dry Eye Subtype

• For evaporative dry eye (meibomian gland dysfunction):
  • Consider lipid-containing artificial tears or liposomal sprays 1, 6
• For aqueous-deficient dry eye (low tear volume):
  • Consider osmolarity-balanced artificial tears 6
  • Tear retention strategies like punctal occlusion may be more beneficial 1

Common Pitfalls to Avoid

• Failing to recognize when to advance therapy from artificial tears to anti-inflammatory agents in moderate to severe disease 1
• Overusing preserved artificial tears, which can cause toxicity to the ocular surface 1, 4
• Neglecting underlying conditions such as blepharitis or meibomian gland dysfunction 1
• Using topical corticosteroids for extended periods (beyond 2-4 weeks) 1