In an adult patient without contraindications, how should Refresh (lubricating ophthalmic solution) eye‑drop products (e.g., Refresh Tears, Refresh Plus, Refresh PM) be prescribed for dry‑eye disease?

How to Prescribe Refresh Eye Drops for Dry Eye Disease

For adults with dry eye disease, prescribe preservative-free Refresh formulations (Refresh Plus or Refresh Tears) at a frequency of 2-4 times daily initially, with preservative-free products mandatory when dosing exceeds 4 times daily to avoid ocular surface toxicity. 1

Initial Prescription Strategy

Product Selection Based on Formulation

• Liquid drops (Refresh Tears, Refresh Plus): Use for daytime symptom relief, as they provide immediate lubrication without visual blur 1
• Gel formulations: Reserve for patients requiring longer-lasting effect between doses 1
• Ointment formulations (Refresh PM): Prescribe specifically for overnight use in patients with nocturnal symptoms, with morning lid hygiene required afterward to prevent blepharitis 1

Dosing Algorithm by Disease Severity

Mild Dry Eye:

• Start with 1 drop in each eye 2 times daily (morning and evening) 1
• Increase frequency up to 4 times daily based on symptom response 1
• Use preserved formulations acceptable at this frequency 1, 2

Moderate Dry Eye:

• Prescribe 1 drop in each eye 3-4 times daily as baseline 3, 1
• Must use preservative-free formulations (Refresh Plus preferred over standard Refresh Tears) 1, 2
• Assess response at 4 weeks; if ineffective, escalate to anti-inflammatory therapy 3

Severe Dry Eye:

• Prescribe 1 drop in each eye every 1-2 hours while awake (up to hourly dosing) 1, 2
• Exclusively preservative-free formulations required 1, 2
• Add Refresh PM ointment at bedtime for overnight protection 1
• Higher hyaluronate percentage formulations offer greater efficacy in severe disease 3

Critical Prescribing Rules

The 4-Times-Daily Threshold

• Preserved artificial tears cause ocular surface toxicity when used >4 times daily 1, 2
• This is a hard cutoff: any patient requiring more frequent dosing must switch to preservative-free formulations 1, 2

When Artificial Tears Alone Are Insufficient

• If symptoms persist after 4 weeks of optimized artificial tear therapy, add cyclosporine 0.05% twice daily as second-line treatment 1, 2
• Consider short-term topical corticosteroids (2-4 weeks maximum) for inflammatory flares before transitioning to cyclosporine 2
• Success rates with artificial tears alone: 65% response rate in observational data 3

Concurrent Treatment Requirements

Mandatory Co-Management

• Always treat underlying blepharitis or meibomian gland dysfunction concurrently with warm compresses (5-10 minutes daily) and lid hygiene 1, 2
• Failure to address these conditions leads to treatment failure regardless of artificial tear frequency 2

Environmental Modifications to Prescribe Alongside Drops

• Eliminate cigarette smoke exposure 1, 2
• Humidify ambient air and use side shields on spectacles 1
• Lower computer screens below eye level and schedule regular breaks every 20 minutes 1, 2
• Increase conscious blinking frequency (>10 times/minute during screen time) 2

Common Prescribing Pitfalls

Errors That Compromise Outcomes

• Never prescribe preserved formulations for use >4 times daily - this worsens ocular surface disease 1, 2
• Do not allow patients to purchase over-the-counter drops independently, as many contain vasoconstrictors or harmful preservatives like benzalkonium chloride 2, 4
• Switching from preserved to preservative-free formulations improves OSDI scores from 56.0 to 28.2 and reduces superficial punctate keratitis from 73% to 46% within 3 weeks 4

When to Advance Therapy

• Reassess at 4 weeks: if OSDI scores remain elevated or corneal staining persists, artificial tears have failed 3, 1
• At this point, add cyclosporine 0.05% (success rates: 74% mild, 72% moderate, 67% severe dry eye) 1, 2
• Consider punctal occlusion only after optimizing all topical therapies 1

Special Populations

Contact Lens Wearers

• Preservative-free formulations are especially critical in this population to avoid lens deposits and irritation 5
• Drops can be instilled with lenses in place if preservative-free 5
• Frequency typically 3 times daily for moderate symptoms in contact lens wearers 6

Patients on Systemic Medications

• Review and modify medications contributing to dry eye (anticholinergics, antihistamines, certain antidepressants, topical glaucoma medications) 2
• Oral antihistamines specifically exacerbate dry eye and should be minimized 1