Due to its multifactorial nature, dry eye treatment can be relatively straightforward or have a significant degree of complexity depending on the individual case. Although there exist general principles that apply to nearly all dry eye treatment regimens, there are elements of these algorithms that will likely differ at least slightly between patients.
Even though there are numerous approaches to treatment, and some may argue there is no single “right way” to treat dry eye, there are certain near-universal pitfalls to avoid when managing dry eye.
Here is a list of some of the most common mistakes to avoid when treating dry eye disease.
1. Using artificial tears as the primary foundation of treatment
While easily the most commonly used treatment for dry eye, artificial tears tend not to be the most effective therapy to manage the condition at a fundamental level, but rather provide a quick, momentary relief of symptoms.1-4 The main reason for this is their effect is primarily palliative rather than therapeutic,2-3 typically providing a few minutes of improved comfort, with their effects then wearing off quickly.
This is the reason I often refer to artificial tears as a “band-aid in a bottle”—they temporarily alleviate symptoms, but they do not treat the root cause of dry eye.2-3 That being said, artificial tears certainly have their place as a mainstay in a dry eye treatment regimen, especially as a means to provide rapid relief, which all patients should have. However, eyecare providers (ECPs) should avoid the mistake of solely relying on lubricating drops to manage a patient’s dry eye.
2. Over-reliance on steroids
In the same vein as an over-dependence on artificial tears is an over-reliance on topical corticosteroids. While steroids do a phenomenal job at quelling inflammation and providing quick symptomatic relief, if not used appropriately, their use likewise essentially masks the symptoms of dry eye rather than addressing the underlying cause.
While it is well-established that inflammation plays an integral role in dry eye,5 understanding the nature of the inflammation present is key to successfully implementing steroid treatment. To simplify this process, I group dry eye-related inflammation into two categories—primary and secondary inflammation.
In primary inflammation, the inflammation itself, whether it be neurological, immunological, or a combination thereof, is the cause of the patient’s dry eye. An example of primary inflammation is dry eye secondary to Sjögren’s syndrome, as the autoimmune condition causes inflammation of the lacrimal gland, leading to disrupted aqueous production. In cases of primary inflammation, the use of steroids is often warranted to address the inflammation that serves as the ultimate cause of dry eye.
However, in cases of secondary inflammation, inflammation is the result of dry eye rather than the root cause. For example, while inflammation can occur in meibomian gland dysfunction (MGD), this inflammation is often the result of chronically obstructed and damaged glands rather than the underlying cause of MGD. If steroids were used in this case, it would indeed reduce the inflammation present, but it would not treat the underlying physical gland obstruction that is ultimately responsible for the inflammation.
So, in this scenario, treatment should primarily focus on encouraging and restoring gland function rather than chasing downstream inflammation.
Risks associated with long-term steroid use
Additionally, the prolonged use of steroids carries the risks of premature cataract formation, elevated intraocular pressure, and glaucoma development.6-12 Consequently, the use of long-term, indefinite steroid use should be avoided whenever possible.
When long-term inflammatory therapy is warranted, the use of an immunomodulator such as Xiidra (lifitegrast ophthalmic solution 5%, B+L), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceuticals), Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), and Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan [An AbbVie Company]) should be implemented to address inflammation without the potentially harmful effects of prolonged steroid use.
3. Avoiding steroid use completely
While an overreliance on steroids in dry eye management can be detrimental, completely avoiding their use entirely can be equally problematic. Therefore, ECPs are recommended to weigh the risks and benefits of steroid use based on the severity of each case’s presentation.
In some cases, leaving significant degrees of inflammation unchecked could be more damaging to the ocular surface than the risks associated with steroid use. If left untreated, inflammation, especially chronic inflammation, can lead to scarring and permanent damage to ocular surface structures and loss of function—such as lid margin scarring and notching that develops in chronic blepharitis, which can impede proper blinking mechanics and meibum secretion.
“In cases of significant inflammation, steroid use is critical to restoring ocular surface integrity; however, topical steroids should be used strategically.”
Typically, treatment can be relatively short (however, some ocular surface conditions do require a prolonged taper), usually 2 to 4 weeks in duration, and the root cause of the inflammation should be addressed concurrently. This method of use makes steroids an excellent option for treating dry eye flares (DEFs), as they can quickly and effectively reduce inflammation without requiring major changes to a patient’s foundational treatment.13
Furthermore, topical steroids can also be used effectively as a “rescue drop.” Similar to a rescue inhaler, when used sparingly, along with proper education and under careful supervision, topical steroids (especially soft steroids like loteprednol, such as Eysuvis) can be used by patients to help get them through the “bad eye days” that all dry eye patients inevitably encounter.
4. Not addressing the entire ocular surface
Again, it is well-known that dry eye is multifactorial in nature. While ECPs know to focus on the “classic” drivers of dry eye, such as MGD or aqueous deficiency, they may not as routinely check for lagophthalmos, which can lead to exposure keratitis or the presence of tear film saponification and/or lash collarettes indicative of bacterial and Demodex blepharitis, respectively.
Ignoring these other contributory ocular surface elements might leave a patient’s treatment incomplete and often results in poor treatment outcomes. Therefore, it is crucial to remember the ocular surface is more than just the cornea, conjunctiva, and meibomian glands but also the eyelids and lashes, tear film, lacrimal and accessory lacrimal glands, and goblet cells as well—each of these elements will need to be individually evaluated and any pathology addressed to completely treat a patient’s dry eye.
5. Routine use of punctal plugs
Although punctal plugs are considered a traditional mainstay of dry eye treatment, they are typically not the optimal treatment option for many cases of dry eye, taking into consideration primary vs. secondary inflammation. Further, despite their widespread use, a systematic review found their efficacy in treating the signs and symptoms of dry eye inconclusive.14
The likely reason for this is that the therapeutic concept underlying the use of punctal plugs is based on an antiquated understanding of dry eye that supposes dryness is caused by a literal lack of tears on the ocular surface. We now know that this is not true for the vast majority of cases of dry eye, as most dry eye stems from poor tear quality rather than quantity.15
Additionally, it has been shown that dry eye patients have elevated levels of pro-inflammatory factors in their tear film,16-18 so the placement of plugs can actually exacerbate inflammation. Therefore, by indiscriminately placing punctal plugs, it is possible that all that is being accomplished is keeping poor-quality tears on the ocular surface for a longer period of time.
And ironically, in cases of true aqueous deficiency where tear production may actually be reduced and the use of punctal plugs theoretically makes sense, inflammation is often a driving factor, leaving the ocular surface open to the potential risk of exacerbating inflammation.
How can punctual plugs negatively impact the ocular surface?
I liken this to plugging the drain of a bathtub filled with dirty water, as, from a homeostatic perspective, the tears are supposed to drain as part of the normal ocular surface function as this aids in the removal of microbes and debris. By occluding the puncta, this runs the risk of disrupting customary ocular surface functionality. In fact, I have encountered numerous dry eye patients displaying chronic ocular surface inflammation that improved after the removal of previously placed punctal plugs.
Since plugs do not treat the underlying causes of dry eye, they, at best, function as an extended-duration artificial tear. However, there are indeed cases where the use of punctal plugs is warranted, and in such cases, I recommend placing dissolvable collagen plugs first to assess their efficacy, followed by semi-permanent silicone plugs if helpful.
6. Jumping straight to scleral lenses
Scleral lenses can be a powerful treatment for dry eye patients, especially those with severe ocular surface disease; however, they are not a cure-all. As I have mentioned previously, if the underlying causes of dry eye are not addressed, even some of the most robust treatments, including scleral lenses, could fail.
This returns back to the principles of optimizing the tear film and ocular surface environment. If the patient has a poor lipid layer due to MGD or unchecked inflammation secondary to uncontrolled blepharitis, the lens surface can dry out, and the eye can remain irritated despite the barrier created by the lens.
Additionally, scleral lens use in the context of dry eye management can be considered a late-stage treatment option, as the primary goal of their use is not to restore the homeostatic function of the ocular surface but rather to create a new “artificial barrier environment.” Accordingly, if the contributing factors of dry eye are successfully addressed, then scleral lenses are often not required from a purely dry eye standpoint.
7. Using advanced treatment procedures in isolation
Advanced treatment procedures for dry eye, such as intense pulsed light (IPL) and thermal pulsation, have been major breakthroughs in managing dry eye. However, one common mistake is using them in isolation with no supportive therapies.
To maximize the benefits of these procedures, patients should also be using foundational dry eye treatments, including omega-3 fatty acid supplementation, lid hygiene, blink exercises, and prescription treatments such as an immunomodulator, if needed. Without these core therapies, even advanced treatments can potentially fail to deliver the desired results.
No matter how effective IPL or thermal pulsation is, no single treatment is the silver bullet that can completely manage dry eye in isolation, making it critical that these patients undergoing these procedures are using foundational therapies as well.
8. Forgetting the basics
Although we now have more dry eye treatment options than ever before, it is crucial to remember the importance of established foundational treatments.
While I have mentioned the numerous factors and complexity of dry eye several times, this is not to undersell the importance of core treatments such as omega-3 fatty acid supplements, warm compresses, lid hygiene, such as hypochlorous acid, blink exercises, artificial tears for comfort, and nocturnal gels or ointments to address incomplete lid closure.
These foundational treatments alone provide the medium for improving the symptoms of dry eye for the majority of patients. In fact, a study by Wojtowicz et al. demonstrated that 70% of dry eye patients became asymptomatic while only using an omega-3 fatty acid supplement and artificial tears.19
So, while it is great to have an ever-growing number of treatment options in our armamentarium, it is important to implement therapies thoughtfully and avoid overcomplicating treatment with polytherapy and neglecting the basics.
9. Not tracking data, progress, treatments, symptoms
With a plethora of subjective and objective testing measures such as dry eye questionnaires, meibography, lipid layer interferometry, noninvasive tear breakup time, as well as numerous treatment options available, it can be easy to lose track of what treatments you have tried with your patients and what each patient’s response was, especially if you are not actively documenting and tracking these data points.
Not only does a lack of data documentation make tracking progress more difficult, but it also can make decision-making more challenging and may even impede progress. Therefore, it is critical to keep track of treatments utilized and the patient’s responses, both objective and subjective, in a logical, consistent fashion. This will allow you to more accurately assess a patient’s progress and determine the most appropriate course of treatment.
10. Not listening to the patient
Another common mistake is not taking the time to listen to our patients’ individual issues when it comes to dry eye and/or failing to take the time to properly educate them. Treating dry eye can be time-consuming, which can be especially challenging given our increasingly jam-packed schedules.
However, taking the time to listen to a patient’s own dry eye story has many benefits:
- Psychologically, the patient feels heard and understood.
- If you listen closely, they will often identify their underlying problems for you.
- You learn what they are most concerned about, for instance, if they are primarily concerned about their eyes watering but you never specifically address their epiphora, they will likely leave the appointment dissatisfied regardless of how good your management plan is because their main concern was not addressed.
Additionally, it is vital to take the time to explain exactly what is causing their dry eye and how each specific treatment used will address that problem. For example, explain that the omega-3 supplement you recommend is to improve their lipid layer stability, and the tea tree oil cleanser you gave them is to reduce the Demodex mites you saw. This education can be time-consuming, but vital because it increases patient understanding and compliance.
If they understand how each treatment could be helping them, patients are more likely to engage and actually follow their treatments. Conversely, it is easier to stop or ignore a treatment when they have no knowledge of its purpose, which is especially true if they are on several therapies at once, as most dry eye patients tend to be as part of their treatment regimen. Ultimately, this increased compliance rooted in education will likely improve treatment outcomes coupled with the potential for greater relief and satisfaction for our patients.
11. Not giving treatments enough time
Dry eye is chronic and progressive, so it typically develops over a long period. Likewise, treatment often requires a significant period of time to take effect. A common mistake is expecting change too quickly, both on the part of the ECP and the patient.
Treatments can often take months before there is a perceptible change, so both the ECP and the patient need to be willing to give a treatment enough time before moving on. Otherwise, you will find yourself stuck in a cycle of jumping from treatment to treatment with no noticeable improvement.
However, there also does come a point where if a treatment has not demonstrated significant benefit, then its use is no longer warranted. The best way to navigate the time element of treatment is to clearly communicate to your patient that their dry eye did not develop overnight and treatment, no matter how good it is, will not be able to fix their issues overnight either. Additionally, as previously discussed, tracking both objective and subjective data will help determine if a specific treatment is having the desired effect over time.
Hence, I tend to explain the timeline in simple terms to patients with a quick script that may extend further than dry eye:
“I’ve diagnosed and treated many patients with your condition. What I’ve found is that as long as it takes you to get into this situation, it will likely take to get you out of it. Based on all your testing and the information we discussed today, we have a customized treatment plan that will provide a strong foundation to move you in the right direction. And it will likely take some time, but if you stick with it, we will be able to get improvement in your condition.”
12. Ignoring contact lens modality
One of the most common complaints in dry eye patients is contact lens intolerance. Obviously, these patients require traditional dry eye treatments; however, if they are not fit into the proper contact lenses, it does not matter how good the treatment plan is if the ocular surface is unable to tolerate the contacts. Contact lenses are essentially foreign bodies, and it is thought that contact lens wear may even be intrinsically inflammatory.20
“However, a goal of many of our dry eye patients is to return to contact lens wear.”
Therefore, the best options for these patients are daily disposable lenses and lens materials that more closely mimic or are more biocompatible with the ocular surface. Daily replacement lenses tend to be more comfortable as patients get a fresh pair every day, so there is less buildup of debris on the lens surface and degradation of the lens itself that can occur with repeated wear associated with biweekly or monthly wear modalities.
Consequently, it is beneficial to fit contact lens-wearing dry eye patients into a daily disposable modality whenever possible.
13. Attributing “non-dry eye issues” to dry eye
One troubling trend I am noticing more and more frequently is dry eye being used as a “punt” diagnosis—especially for complaints of blurry vision. Rather than perform a thorough examination of all the possible causes of blurred vision, some ECPs might see the patient has dry eye and will automatically attribute any complaints of blurriness to that dry eye.
There have been numerous times I have seen a patient referred for a dry eye evaluation, but their only complaint is blurred vision, and the ultimate cause is something other than dry eye. Although dry eye certainly can and does cause blurred vision, it tends to have a very specific presentation: blur that is transient and clears with blinking.
While this pattern is characteristic of dry eye-related blur, blur that is persistent even with blinking and reduces vision to worse than 20/40 is typically due to a cause other than dry eye (unless the patient has significant corneal surface disruption such as diffuse punctate epithelial keratitis [PEK], which can sometimes significantly reduce visual acuity; however, this is easily identifiable with slit lamp evaluation). This reduced vision may be due to cataracts, neurotrophic keratitis (NK), posterior capsular opacification, early macular degeneration, keratoconus, or even simple uncorrected refractive error.
The key takeaway here is the importance of looking at the eye as a whole, even when focusing on dry eye and the ocular surface.
The value of performing a comprehensive eye exam
A perfect example of why this is so crucial is the case of a patient that was referred to me for a dry eye evaluation, but her biggest complaint was a persistent visual disturbance in her left eye only. This presentation was inconsistent with dry eye, so I had the patient perform a visual field and found a unilateral left hemianopsia in the left eye. The cause of this visual field defect ended up being an optic nerve sheath meningioma that required surgery in a matter of weeks.
This is the reason why every patient I see for a dry eye evaluation must also have a comprehensive eye exam or have received one elsewhere to ensure that a visually devastating disease or serious systemic condition (that could be potentially life-threatening) like cancer, macular degeneration, or glaucoma is not missed.
Therefore, before attributing blurry vision or other visual disturbances entirely to dryness, make sure it makes sense, fits the pattern, and you have ruled out other potential causes—whether they be cataracts, retinal disease, or optic neuropathy.
Final word
We all have the best intentions when treating our dry eye patients. Although there are numerous treatment approaches to manage this multifactorial disease, the optimal path to potential success tends to lie in simplicity and clarity.
So the next time you are about to see a new dry eye patient or even working with one you have been treating for years, consider how you might modify your treatment technique using this information as your guide.
