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

From the Guidelines

Dry eye treatment should start with a stepwise approach, beginning with artificial tears, and may progress to prescription medications like Restasis (cyclosporine 0.05%) or Xiidra (lifitegrast 5%) for moderate to severe cases, as these have been shown to reduce inflammation and increase tear production 1. The treatment of dry eye syndrome involves a multifaceted approach, addressing the underlying causes of the condition, including decreased tear production, increased tear evaporation, and inflammation of the ocular surface. Some key considerations for treatment include:

• Artificial tears, such as Systane, Refresh, or TheraTears, used 4-6 times daily for immediate relief, with preservative-free formulations recommended for frequent use to avoid irritation 2.
• Lifestyle modifications, including regular breaks from screen time, using a humidifier in dry environments, and staying hydrated.
• For moderate to severe cases, prescription medications like Restasis (cyclosporine 0.05%) or Xiidra (lifitegrast 5%) may be used twice daily to reduce inflammation and increase tear production, with cyclosporine demonstrating a statistically significant increase in Schirmer test results compared to vehicle at 6 months 1.
• Warm compresses applied to closed eyelids for 5-10 minutes daily can help unclog oil glands that contribute to tear film stability.
• Omega-3 fatty acid supplements (1000-2000mg daily) may also improve symptoms by reducing inflammation. It is essential to educate patients about the natural history and chronic nature of dry eye, setting realistic expectations for therapeutic goals and discussing the importance of treating any causative factors that are amenable to treatment 3. In severe cases, additional treatments may be considered, including permanent punctal occlusion, autologous serum or plasma rich in growth factors drops, and oral medications like cevimeline or pilocarpine, which have been shown to improve ocular irritation symptoms and aqueous tear production in patients with Sjögren’s syndrome 4. Ultimately, the goal of treatment is to restore the normal tear film that protects and lubricates the eye, addressing the underlying causes of dry eye and improving symptoms and quality of life for patients.

From the Research

Dry Eye Treatment Options

• The use of topical anti-inflammatory drugs has become important in treating dry eye disease, including tear replacement, serum eye drops, and mucolytic eye drops 5.
• Topical application of corticosteroids and cyclosporin A is commonly used in moderate to severe forms of dry eye disease 5.
• Treatment of Meibomian gland dysfunction is crucial in managing evaporative dry eye 5.

24-Hour Management of Dry Eye Disease

• Symptom severity of dry eye disease varies over a 24-hour period, with symptoms typically worse upon waking and deteriorating towards the evening 6.
• Treatment strategies should be matched to the variations in severity and environmental factors over a 24-hour period 6.
• Artificial tears are used during the day to moisturize the ocular surface, while gels are used at night due to their higher viscosity and longer ocular surface retention time 6.

Currently Approved and Upcoming Treatments

• Currently approved treatments for dry eye disease include cyclosporine formulations, XIIDRA (lifitegrast), EYSUVIS (loteprednol etabonate), and MIEBO (perfluorohexyloctane) 7.
• Medical devices approved for treating dry eye disease due to Meibomian gland dysfunction include Lumenis OptiLight, TearCare system, and TearScience LipiFlow thermal pulsation system 7.
• Hundreds of clinical studies are evaluating newer treatments, including cyclosporine formulations, IC 265, OK-101, and OXERVATE (cenegermin-bkbj) 7.

Diagnosis and Treatment Strategies

• Dry eye is a common complaint, with one in four patients attending ophthalmic clinics reporting symptoms 8.
• Aqueous-layer deficiency is the most common form of dry eye, frequently caused by decreased secretion of tears by the lacrimal glands 8.
• Tear replacement or preservation using artificial tears and/or punctal occlusion are the mainstay of treatment, with newer therapies designed to modify the underlying disease process 8.

Efficacy and Safety of Artificial Tears

• A preservative-free artificial tear containing carboxymethylcellulose and hyaluronic acid was found to be effective and well-tolerated in a randomized, controlled, multicenter study 9.
• The artificial tear significantly improved symptoms and signs of dry eye, including ocular surface staining and tear break-up time 9.
• The new formulation demonstrated a greater potential for symptom relief compared to a formulation containing carboxymethylcellulose alone 9.