Treatment for Dry Eyes
Start with preservative-free artificial tears containing methylcellulose or hyaluronate as first-line therapy, using them at least twice daily and increasing frequency based on symptom severity. 1, 2
Step 1: Initial Management for All Patients
Environmental and Lifestyle Modifications
- Eliminate cigarette smoke exposure, which damages the lipid layer of the tear film and tear proteins 1
- Humidify ambient air and avoid direct air drafts by using side shields on spectacles 1
- Lower computer screens below eye level to decrease lid aperture, schedule regular breaks, and consciously increase blinking during screen time 1
- Identify and eliminate offending medications such as antihistamines or diuretics that worsen dry eye 1
First-Line Artificial Tears
- Use preservative-free formulations when applying more than 4 times daily to avoid preservative-induced toxicity 1, 2
- Polymeric-based lubricants (methylcellulose 0.5-1% or hyaluronic acid/hyaluronate) are the mainstay of treatment 2
- Lipid-containing artificial tears should be considered if meibomian gland dysfunction is present 1
- Liquid drops for daytime use, gels for longer-lasting effect, and ointments for overnight protection 2
Address Contributing Factors
- Treat concurrent blepharitis or meibomian gland dysfunction with lid hygiene and warm compresses 1, 2
- Correct eyelid abnormalities including trichiasis, lagophthalmos, entropion, or ectropion 1, 2
Step 2: Moderate Dry Eye (When Artificial Tears Are Inadequate)
Anti-Inflammatory Prescription Medications
Cyclosporine 0.05% ophthalmic emulsion (Restasis) twice daily, 12 hours apart, is effective in 74%, 72%, and 67% of patients with mild, moderate, and severe dry eye respectively 1, 2, 3
Lifitegrast 5% ophthalmic solution (Xiidra) blocks LFA-1/ICAM-1 interaction and improves both signs and symptoms 1, 2
Varenicline nasal spray (Tyrvaya) activates nicotinic acetylcholine receptors on the trigeminal nerve to stimulate natural tear production 1, 2
Perfluorohexyloctane (water-free lipophilic liquid) for lipid layer deficiency 1
Short-Term Corticosteroids
- Topical corticosteroids for 2-4 weeks maximum to decrease ocular irritation and corneal staining 1, 2
- Avoid extended use due to risk of infections and increased intraocular pressure 2
Mechanical Interventions
- Punctal occlusion with temporary silicone plugs for tear retention after optimizing topical therapy 1, 2
- Moisture chamber spectacles/goggles for additional tear conservation 1
- In-office thermal pulsation devices for meibomian gland expression 1
Oral Antibiotics
- Oral tetracycline or macrolide antibiotics for meibomian gland dysfunction with inflammatory component 1
Step 3: Severe Dry Eye (When Step 2 Options Are Inadequate)
Advanced Therapies
Autologous serum eye drops improve ocular irritation symptoms and corneal/conjunctival staining, particularly effective in Sjögren's syndrome 2
Oral secretagogues (pilocarpine 5mg four times daily or cevimeline) stimulate tear production in Sjögren's syndrome patients, though side effects like excessive sweating may occur 2
Scleral contact lenses can provide symptomatic relief in selected severe cases, though infection risk increases 2
Surgical Options
- Permanent punctal cautery for long-term tear retention 1, 2
- Amniotic membrane grafts for severe ocular surface disease 1
- Tarsorrhaphy or minor salivary gland transplantation for refractory cases 1
Critical Pitfalls to Avoid
- Do not use preserved artificial tears more than 4 times daily as this causes ocular surface toxicity 2
- Do not delay advancing from artificial tears to anti-inflammatory agents when symptoms persist despite adequate lubrication 2
- Do not use topical corticosteroids beyond 2-4 weeks without close monitoring for complications 2
- Do not neglect underlying blepharitis or meibomian gland dysfunction as these exacerbate dry eye and prevent treatment success 2
- Recognize that symptoms and signs correlate poorly in dry eye disease, so treat based on clinical presentation even when objective signs are minimal 1