What is the treatment for dry eyes in the elderly?

Treatment for Dry Eyes in the Elderly

For elderly patients with dry eye disease, preservative-free artificial tears containing methylcellulose or hyaluronate are recommended as first-line treatment, with frequency adjusted based on symptom severity. 1

Treatment Algorithm Based on Severity

First-Line Treatment for Mild Dry Eye

• Use preservative-free artificial tears when applying more than four times daily 2, 1
• Address environmental factors:
  • Eliminate exposure to cigarette smoke which adversely affects the tear film lipid layer 2, 1
  • Humidify ambient air and avoid air drafts using side shields on spectacles 2, 1
  • Lower computer screens below eye level to decrease eyelid aperture 2
  • Schedule regular breaks and increase conscious blinking during computer use 2, 1
• Treat concurrent conditions:
  • Address blepharitis or meibomian gland dysfunction if present 2, 1
  • Correct eyelid abnormalities such as trichiasis, lagophthalmos, entropion, or ectropion 2, 1

Second-Line Treatment for Moderate Dry Eye

• Add anti-inflammatory therapies when artificial tears are insufficient:
  • Cyclosporine ophthalmic solution 0.05% (Restasis) has demonstrated success in 74%, 72%, and 67% of patients with mild, moderate, and severe dry eye, respectively 1
  • Lifitegrast ophthalmic solution 5% (Xiidra) is indicated for the treatment of signs and symptoms of dry eye disease 3
  • Short-term topical corticosteroids (2-4 weeks maximum) can be used for refractory cases 1
• Consider different artificial tear formulations:
  • Liquid drops for daytime use 1
  • Gels for longer-lasting effect 1
  • Ointments for overnight use 1
  • Lipid-containing eye drops for patients with meibomian gland dysfunction 1

Advanced Treatments for Severe Dry Eye

• Punctal occlusion using temporary silicone plugs or permanent thermal/laser cautery to retain tears 1
• Autologous serum eye drops for severe cases, particularly in Sjögren's syndrome 1
• Oral medications like cevimeline or pilocarpine (5mg four times daily) to stimulate tear production in Sjögren's syndrome 1
• Specialized contact lenses such as rigid gas-permeable scleral lenses for severe cases 1

Specific Artificial Tear Recommendations

• Polymeric-based lubricants including methylcellulose-based tears and hyaluronic acid/hyaluronate-based tears are the mainstay of treatment 1
• Carboxymethylcellulose (0.5-1%) and carmellose sodium are effective options 1
• Lipid-based artificial tear formulations may be more effective and better tolerated than standard formulations for some patients 4
• Frequency of application should be adjusted based on symptom severity, ranging from twice daily to hourly 1

Common Pitfalls to Avoid

• Overuse of preserved artificial tears can cause toxicity to the ocular surface 1
• Extended use of topical corticosteroids beyond 2-4 weeks can lead to complications including infections and increased intraocular pressure 1
• Failing to recognize when to advance therapy from artificial tears to anti-inflammatory agents in moderate to severe disease 1
• Neglecting underlying conditions such as blepharitis or meibomian gland dysfunction 1
• Inadequate treatment of severe dry eye can lead to corneal ulceration and vision loss 1

Special Considerations for Elderly Patients

• Overnight protection with ointments is important for nocturnal symptoms 1
• Morning lid hygiene should follow overnight ointment use to prevent blepharitis 1
• Manual dexterity limitations may affect the practicality of frequent tear instillation 2
• Concurrent medications like antihistamines or diuretics may exacerbate dry eye and should be addressed 2