What are the management options for keratoconjunctivitis sicca (dry eye syndrome)?

From the Guidelines

Dry eye management involves a stepwise approach starting with lifestyle modifications and artificial tears, with the most recent evidence suggesting that autologous serum tears, scleral contact lenses, or oral medications like cevimeline may be necessary for severe cases. Begin by addressing environmental factors like reducing screen time, using humidifiers, and avoiding direct air flow to the eyes, as emphasized in the dry eye syndrome preferred practice pattern 1. For mild cases, use preservative-free artificial tears 4-6 times daily. If symptoms persist, consider lipid-based tears like Systane Balance or Refresh Optive Advanced for evaporative dry eye.

Some key considerations for managing dry eye syndrome include:

• Patient education on the natural history and chronic nature of dry eye, as well as realistic expectations for therapeutic goals 1
• Addressing contributory factors, such as tear replacement and treating any causative factors that are amenable to treatment 1
• Using autologous serum and autologous plasma rich in growth factors drops, which have been reported to improve ocular irritation symptoms as well as conjunctival and corneal dye staining in patients with Sjögren’s syndrome and GVHD 1
• Considering oral medications like cevimeline, which have been found to improve ocular irritation symptoms and aqueous tear production, especially for patients with combined dry eye and dry mouth (Sjögren’s syndrome) 1

For severe cases, autologous serum tears, scleral contact lenses, or oral medications like cevimeline may be necessary, as these treatments have been shown to improve symptoms and quality of life in patients with severe dry eye syndrome 1. Additionally, omega-3 supplements (1000-2000mg daily) can improve meibomian gland function, and warm compresses for 5-10 minutes twice daily followed by gentle lid massage can help release oils from meibomian glands. Lid hygiene with dedicated cleansers can also treat associated blepharitis. This multi-modal approach addresses the inflammatory cycle of dry eye disease while providing symptomatic relief and targeting underlying causes.

From the FDA Drug Label

Cyclosporine ophthalmic emulsion, 0.05% is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca. Increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs. Instill one drop of cyclosporine ophthalmic emulsion, 0.05% twice a day in each eye approximately 12 hours apart.

The management options for keratoconjunctivitis sicca (dry eye syndrome) include:

• Cyclosporiloctrine ophthalmic emulsion, 0.05% to increase tear production, specifically in patients with presumed suppressed tear production due to ocular inflammation 222
• Not using cyclosporine ophthalmic emulsion, 0.05% in patients currently taking topical anti-inflammatory drugs or using punctal plugs, as increased tear production was not seen in these cases
• Dosage: instilling one drop of cyclosporine ophthalmic emulsion, 0.05% twice a day in each eye, approximately 12 hours apart 2

From the Research

Management Options for Keratoconjunctivitis Sicca (Dry Eye Syndrome)

The management options for keratoconjunctivitis sicca (dry eye syndrome) include:

• Artificial tear drops to replace or preserve tears 3, 4, 5
• Tear retention treatment, such as punctal occlusion, to aid in the preservation of natural tears 3, 6, 7
• Stimulation of tear secretion 3
• Anti-inflammatory drugs, such as cyclosporin A (CsA) or corticosteroids, to reduce inflammation on the ocular surface 3, 4
• Lid hygiene to treat hyperevaporative dry eye 4
• Collagen or silicon plugs for partial occlusion of the efferent lacrimal ducts to treat severe hyposecretory dry eye 4
• Orally administered tetraycycline derivatives and omega-3 or omega-6 fatty acids 4
• Humidification and improved nutrition to relieve symptoms 5
• Warm compresses and physician referrals for more aggressive treatment 5

Treatment Approaches

Different treatment approaches have been developed to modify the underlying disease process, including:

• Microspheres, implants, and liposomes for the administration of CsA subconjunctivally to enhance its efficiency 3
• New anti-inflammatory drugs and secretagogues 4
• Topical androgens 4

Punctal Occlusion

Punctal occlusion is a mechanical treatment that blocks the tear drainage system to aid in the preservation of natural tears on the ocular surface. The evidence on the effectiveness of punctal plugs for managing dry eye is inconclusive due to heterogeneity in trial methodology and the type of punctal plug investigated 6, 7. However, punctal plugs may be associated with some benefits, such as reduced ocular surface staining and improved tear film stability, although the differences are small and possibly clinically unimportant 7.