What treatment options are available for a patient experiencing dry eye symptoms, particularly one who may benefit from using Refresh Tears (artificial tears)?

Refresh Tears for Dry Eye Disease

For mild dry eye symptoms, start with preservative-free artificial tears containing methylcellulose or hyaluronate (like Refresh Tears) applied at least twice daily, increasing frequency up to hourly based on symptom severity. 1

First-Line Treatment Algorithm

Artificial tears are the mainstay of dry eye treatment and should be your initial therapy. 1 The American Academy of Ophthalmology specifically recommends polymeric-based lubricants including methylcellulose-based tears and hyaluronic acid/hyaluronate-based tears as first-line treatment. 1

Formulation Selection

• Use preservative-free formulations when applying more than 4 times daily to avoid ocular surface toxicity. 2, 1
• For mild use (≤4 times per day), preserved tears are acceptable. 1
• Liquid drops work best for daytime use, gels provide longer-lasting effect, and ointments should be reserved for overnight protection. 1, 3
• If using overnight ointments, perform morning lid hygiene to prevent blepharitis. 3

Dosing Strategy

• Begin with at least twice daily application and increase frequency based on symptom severity, up to hourly if needed. 1, 3
• A 2023 systematic review found that artificial tears improve dry eye symptoms within one month when applied about four times daily, though signs may take several months to improve. 4

Environmental and Behavioral Modifications (Essential Adjuncts)

• Eliminate all cigarette smoke exposure completely, as smoking adversely affects the tear film lipid layer. 2, 1
• Humidify ambient air and use side shields on spectacles to minimize air draft exposure. 2, 1
• Lower computer screens below eye level to decrease eyelid aperture and schedule regular 20-minute breaks. 2, 1
• Increase conscious, full blinking during computer use and reading activities. 1

When to Escalate Beyond Artificial Tears

If symptoms persist after 2-4 weeks of optimized artificial tear therapy, advance to anti-inflammatory agents. 1, 5

Second-Line Options for Moderate Dry Eye

• Add cyclosporine 0.05% ophthalmic emulsion one drop in each eye twice daily (approximately 12 hours apart), with demonstrated success rates of 74% in mild, 72% in moderate, and 67% in severe dry eye. 2, 3
• Lifitegrast 5% ophthalmic solution is an alternative that blocks LFA-1/ICAM-1 interaction, dosed twice daily approximately 12 hours apart. 6
• Short-term topical corticosteroids (maximum 2-4 weeks only) can decrease acute ocular irritation and corneal staining, but extended use beyond 4 weeks risks serious complications including infections and increased intraocular pressure. 1, 3

Treating Underlying Conditions

• Address concurrent blepharitis or meibomian gland dysfunction with warm compresses for 5-10 minutes twice daily and gentle lid massage. 2, 1, 5
• For patients with meibomian gland dysfunction, use lipid-containing artificial tears specifically. 1, 5
• Correct eyelid abnormalities such as trichiasis, lagophthalmos, entropion, or ectropion. 2, 1

Critical Pitfalls to Avoid

• Preserved artificial tears used more than 4 times daily cause ocular surface toxicity—switch to preservative-free formulations at this frequency. 1, 3, 5
• Failing to recognize when to advance from artificial tears to anti-inflammatory agents leads to inadequate treatment of moderate to severe disease. 1, 5
• Neglecting underlying blepharitis or meibomian gland dysfunction exacerbates dry eye regardless of artificial tear use. 1, 5
• Oral antihistamines and diuretics can worsen dry eye symptoms and should be avoided or minimized. 2, 1

Red Flags Requiring Ophthalmology Referral

• Moderate or severe eye pain unresponsive to initial therapy. 3, 5
• Lack of response after 2-4 weeks of optimized treatment. 3, 5
• Corneal infiltration, ulceration, or any vision loss. 3, 5