What are the clinical symptoms and management options for dry eye (Keratoconjunctivitis Sicca) diagnosis?

From the Guidelines

Dry eye disease management should prioritize a stepwise approach, starting with artificial tears and lifestyle modifications, and progressing to more advanced treatments such as autologous serum tears, scleral contact lenses, or punctal plugs for severe cases, as recommended by the most recent guidelines 1.

Diagnosis and Clinical Symptoms

Dry eye disease is diagnosed through a combination of clinical symptoms and diagnostic tests. Patients typically present with eye irritation, burning, redness, light sensitivity, blurred vision, and a sensation of grittiness or foreign body.

Management

Management begins with identifying and addressing underlying causes such as medication side effects, environmental factors, or systemic conditions. First-line treatment includes artificial tears (preservative-free formulations preferred) used 4-6 times daily, with options like Systane Ultra, Refresh Optive, or TheraTears.

• For moderate cases, add anti-inflammatory therapy such as cyclosporine 0.05% (Restasis) twice daily or lifitegrast 5% (Xiidra) twice daily.
• Topical corticosteroids like loteprednol 0.5% can be used short-term (2-4 weeks) for flare-ups.
• Oral omega-3 fatty acid supplements (1000-2000mg daily) may help improve tear film stability.

Severe Cases

For severe cases, autologous serum tears, scleral contact lenses, or punctal plugs to block tear drainage may be necessary 1.

• Lifestyle modifications are crucial and include maintaining proper hydration, using humidifiers, taking regular screen breaks with the 20-20-20 rule (every 20 minutes, look 20 feet away for 20 seconds), avoiding direct air flow to the eyes, and using warm compresses followed by lid massage for meibomian gland dysfunction.

Patient Education

Patient education is a critically important aspect of successful management of this condition, as emphasized in recent guidelines 1. The ophthalmologist should educate the patient about the natural history and chronic nature of dry eye, setting realistic expectations for therapeutic goals.

Chronic Nature

Dry eye is often chronic and requires ongoing management, with treatment adjusted based on symptom severity and response to therapy, as highlighted in the latest research 1.

From the FDA Drug Label

Cyclosporca is an immunosuppressive agent when administered systemically. In patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca, cyclosporca emulsion is thought to act as a partial immunomodulator. Lifitegrast ophthalmic solution 5% is indicated for the treatment of the signs and symptoms of dry eye disease (DED). The clinical symptoms management of dry eye diagnosis can be treated with medications such as cyclosporca and lifitegrast.

• Cyclosporca is thought to act as a partial immunomodulator in patients with keratoconjunctivitis sicca.
• Lifitegrast is indicated for the treatment of the signs and symptoms of dry eye disease (DED) 23

From the Research

Clinical Symptoms of Dry Eye

• Dry eye disease (DED) is characterized by varying symptom severity over a 24-hour period, typically worse upon waking and deteriorating towards the evening 4
• The tear film characteristics, such as levels of inflammation, pH, osmolarity, volume, and stability, also differ between night and day, and over the course of the day itself 4

Management of Dry Eye Disease

• The management of DED encompasses both pharmacologic and nonpharmacologic approaches, including avoidance of exacerbating factors, eyelid hygiene, tear supplementation, tear retention, tear stimulation, and anti-inflammatory agents 5
• Artificial tears are the mainstay of DED therapy, but they only improve symptoms and objective findings, without resolving the underlying inflammation 5
• Topical corticosteroids are effective anti-inflammatory agents, but are not recommended for long-term use due to their adverse-effect profiles 5
• Topical cyclosporine is safe for long-term use and is disease-modifying rather than merely palliative 5
• Lifitegrast, a novel drug, has been approved for the treatment of DED, and it works by hindering the T-cell activation, release of inflammatory mediators, and consequently inhibiting the inflammatory pathways in DED 6

Treatment Strategies

• Treatment strategies for DED must be matched to the variations in the severity of DED and to the environments that eyes are subjected to over a 24-hour period 4
• A combination of artificial tears during the day and gels at night-time can provide optimal 'around-the-clock' DED management 4
• The use of topical anti-inflammatory drugs, such as corticosteroids and cyclosporin A, is more commonly used in moderate to severe forms of dry eye disease 7
• The consistent treatment of Meibomian gland dysfunction is also of particular importance in the management of DED 7