What are the best eyedrops (artificial tears) for a patient experiencing eye dryness, irritation, and burning?

Best Eyedrops for Eye Dryness, Irritation, and Burning

Start with preservative-free artificial tears containing polyethylene glycol or hyaluronic acid/hyaluronate, applied at least twice daily and increased up to hourly based on symptom severity. 1

First-Line Treatment: Artificial Tears Selection

Preservative-free formulations are mandatory when using drops more than 4 times daily to avoid ocular surface toxicity. 1, 2, 3

Most Effective Formulations (in order of evidence strength):

• Polyethylene glycol-based artificial tears are more effective than carboxymethylcellulose or hydroxypropyl methylcellulose for symptom relief. 4

• Combination formulations (containing multiple active ingredients) are more effective than single-ingredient artificial tears. 4

• Methylcellulose-based or hyaluronic acid/hyaluronate-based tears are recommended as first-line polymeric lubricants. 1, 3

• Carboxymethylcellulose (0.5-1%) and carmellose sodium are acceptable alternative options. 1

Application Strategy by Time of Day:

• Use liquid drops during daytime for immediate relief. 1, 3

• Apply gels for longer-lasting effect when extended protection is needed. 1, 3

• Use ointments overnight for nocturnal symptoms, followed by morning lid hygiene to prevent blepharitis. 1, 3

When Artificial Tears Alone Are Insufficient

If symptoms persist after 2-4 weeks of optimized artificial tear therapy (used at least 4 times daily), advance to anti-inflammatory agents. 1, 2, 3

Second-Line Options:

• Add topical cyclosporine 0.05% (Restasis) twice daily for moderate dry eye with demonstrated success rates of 74% in mild, 72% in moderate, and 67% in severe dry eye. 1, 2

• Lifitegrast 5% (Xiidra) twice daily is an alternative second-line agent that blocks LFA-1/ICAM-1 interaction and improves both signs and symptoms. 1, 5

• Short-term topical corticosteroids (2-4 weeks maximum) can be used for acute exacerbations to decrease irritation and corneal staining, but never extend beyond 4 weeks due to risks of infection, increased intraocular pressure, and cataract formation. 1, 2

Special Considerations for Underlying Conditions

Always treat concurrent blepharitis or meibomian gland dysfunction with warm compresses (5-10 minutes twice daily) and gentle lid massage, as failing to address these conditions will cause treatment failure regardless of artificial tear use. 1, 2, 3

• Use lipid-containing eye drops specifically if meibomian gland dysfunction is present to supplement the deficient lipid layer. 1, 3

Critical Environmental Modifications

• Eliminate all cigarette smoke exposure completely, as smoking adversely affects the tear film lipid layer. 1, 2, 3

• Humidify ambient air and use side shields on spectacles to minimize air draft exposure. 1, 2, 3

• Lower computer screens below eye level and schedule breaks every 20 minutes to increase full blinking during screen time. 1, 2, 3

Common Pitfalls to Avoid

• Never use preserved artificial tears more than 4 times daily as this causes ocular surface toxicity; switch to preservative-free formulations at this frequency. 1, 2, 3

• Avoid or minimize oral antihistamines in patients with dry eye as they exacerbate symptoms. 1

• Never extend topical corticosteroid use beyond 4 weeks due to serious complications including infections, increased IOP, and cataract development. 2

• Do not use topical corticosteroids in patients with glaucoma or ocular hypertension due to risk of IOP elevation. 2

When to Refer to Ophthalmology

Refer immediately if any of the following occur: 2, 3

• Moderate or severe eye pain
• Lack of response after 2-4 weeks of optimized treatment
• Corneal infiltration or ulceration
• Vision loss or visual disturbances
• Need for steroids beyond 4 weeks