How should Refresh artificial tears be prescribed for an adult patient with dry‑eye symptoms?

How to Prescribe Refresh Eye Drops for Dry Eye

For adult patients with dry eye symptoms, prescribe preservative-free Refresh artificial tears (carboxymethylcellulose 0.5-1%) starting at least twice daily, increasing frequency up to hourly as needed, but switch to preservative-free formulations if using more than 4 times daily to avoid ocular surface toxicity. 1, 2

Initial Prescription Strategy

Starting Regimen

• Begin with Refresh artificial tears (carboxymethylcellulose-based) at least twice daily, with instructions to increase frequency based on symptom severity up to hourly if needed 1, 2
• For patients requiring more than 4 applications daily, prescribe only preservative-free formulations (such as Refresh Plus) to prevent preservative-induced ocular surface toxicity 1, 2, 3
• Add nighttime ointment for overnight symptom control, followed by morning lid hygiene to prevent blepharitis 1

Formulation Selection

• Carboxymethylcellulose (0.5-1%) or carmellose sodium are effective first-line options for general dry eye 2
• Liquid drops work best for daytime use, while gels provide longer-lasting effects and ointments are reserved for overnight use 2
• Lipid-containing formulations should be selected specifically for patients with meibomian gland dysfunction 2

When to Escalate Beyond Artificial Tears

Timing for Advancement

• If symptoms persist after 2-4 weeks of optimized artificial tear use, escalate to anti-inflammatory therapy with topical cyclosporine 0.05% 1, 3
• Consider short-term topical corticosteroids (loteprednol) for 2-4 weeks maximum during acute exacerbations, but monitor for increased intraocular pressure and cataracts 1, 3

Critical Concurrent Treatments

• Always evaluate and treat underlying blepharitis or meibomian gland dysfunction with warm compresses, lid hygiene, and lid massage, as these conditions coexist in the majority of dry eye patients and will cause treatment failure if ignored 1, 2, 3
• Correct any eyelid malposition (lagophthalmos, entropion, ectropion) that may be contributing to symptoms 1, 2

Environmental and Behavioral Modifications

• Eliminate cigarette smoke exposure, which adversely affects the tear film lipid layer 1, 2
• Humidify ambient air, use side shields on glasses, and avoid air drafts 1, 2
• Lower computer screens below eye level and encourage conscious blinking during screen time 1, 2
• Take regular breaks every 20 minutes during prolonged visual tasks 2

Common Prescribing Pitfalls to Avoid

• Never prescribe preserved artificial tears for use more than 4 times daily, as preservatives cause ocular surface toxicity and worsen dry eye 1, 2, 3
• Do not delay escalation to anti-inflammatory therapy if symptoms persist despite 2-4 weeks of optimized artificial tear use 1, 2
• Never extend topical corticosteroid use beyond 2-4 weeks due to risks of infections, increased intraocular pressure, and cataract formation 1, 3
• Avoid prescribing artificial tears alone without addressing concurrent blepharitis or meibomian gland dysfunction, as this limits treatment effectiveness 1, 2, 3
• Review and modify systemic medications that may exacerbate dry eye, including oral antihistamines, certain antidepressants, anticholinergics, and topical glaucoma medications 2

Expected Clinical Response

• Carboxymethylcellulose 0.5% provides temporary but significant improvement in visual acuity, with effects lasting approximately 3 minutes per application 4
• When artificial tears prove insufficient, cyclosporine 0.05% demonstrates success rates of 74% in mild, 72% in moderate, and 67% in severe dry eye 1, 2