As Eyes On Dry Eye 2026 highlights, there are a lot of exciting things going on in the dry eye disease (DED) space—however, the rapid pace of innovation can sometimes make the decision of how to most effectively manage your dry eye patients a challenge. When this is the case, it can be helpful to ask an expert, something attendees got to do as Damon Dierker, OD, FAAO, once again took up position in the Hot Seat to answer any and all DED questions. Here are some of the things he was asked—and what he had to say in response:
“Should patients on Restasis add any of these new drops to see if there's more improvement?”
I think the question to ask is really whether we should be layering therapies. For patients on cyclosporine that continue to have symptoms, we can switch, add, or occasionally start from scratch. This requires us to examine a patient’s history and their symptoms. If someone's on Restasis, I’ll typically also consider whether it’s doing what I want it to. Because if not, I know there’s very good data—such as the Phase 4 study by Sun Pharmaceutical—demonstrating I can switch that patient to a next-generation cyclosporine and probably have a better outcome. When long-term Restasis patients were switched to Cequa, after a month, not only did the majority state their preference for Cequa, but their corneal staining also improved. Similarly, if the patient’s primary concern is burning and stinging or issues with access, Vevye can play a role. There’s more data supporting switching to Cequa than for Vevye, but that's how I would approach it.
But to your question of potentially adding something, I’d focus on whether inflammation is being appropriately managed; and whether the cyclosporine is providing value. If so, I'll assess other potential therapeutic targets. Because when we’re adding something, we need to do so with intentionality. I typically won’t layer an additional cyclosporine product—though I have, very rarely, had patients that have done really well once Xiidra has been added. More commonly, I work to further improve tear production, such as with Tryptyr or Tyrvaya. I also consider in-office treatments to treat other disease drivers; topical steroids such as Eysuvis for any breakthrough symptoms, and so patients don’t have to call my office mid-flare; and other options such as amniotic membranes for corneal issues.
As I continue to treat, I’ll continually monitor things. For most of these patients, we’re not necessarily aiming for them to be asymptomatic, but instead that they have more good days—with fewer breakthroughs, and therapy that's both accessible and tolerable—than not. We’re talking about lifelong management, so I want to do the best I can to simplify things.
“What are your thoughts on low-level light therapy?”
I'm a fan of low-level light therapy (LLLT). It’s something I use pretty routinely because I believe it helps with inflammation, having a photobiomodulatory effect while also providing some endogenous heat, which helps me remove some meibomian gland obstruction.
For people with mild-to-moderate dry eye with inflammation, who also have some meibomian gland obstruction, LLLT can be a first-line therapy in-office treatment. You can also use LLLT in patients that have acute hordeola or chalazia; I've also used it in conjunction with IPL as well as with Tixel. It has a lot of different applications, and I've had superb experiences with it.
“Is there any treatment that is basically like hitting the easy button?”
Xdemvy. This is probably my most frequent ocular surface disease (OSD) prescription in 2026. Demodex blepharitis (DB) is so common. It is underdiagnosed. My practice is part of a study looking at a hundred consecutive patients of all ages who were both symptomatic and asymptomatic—and not just those with DED or OSD. It found the prevalence of collarettes was 60%—consistent with the literature.1 So more often than not, your patient has DB. For treating these patients and improving their quality of life, I'll hit the easy button of Xdemvy. It’s a six-week course, that eradicates the demodex mites for a year or longer with a 90–95% success rate. Nothing else has that level of response in that predictable of a manner—and through BlinkRX, we're able to offer it cost-effectively to the vast majority of patients.
We’re continuing to learn how much of an issue DB is, not only for symptoms of anterior blepharitis, but also the impact on meibomian gland dysfunction, tear breakup time, recurrent chalazia, and recurrent marginal keratitis. This is why I’ve started taking a DB-first mindset: if I see it in an ocular surface patient, I’ll manage it first and then treat any remaining collateral damage.
“Are you doing corneal sensitivity testing?”
Yes; you can't reach a neurotrophic keratitis diagnosis without it. I sometimes still use a cotton wisp, but prefer to use non-invasive, non-contact testing. For the past two years, we've used the Brill esthesiometer, meaning this testing can actually be delegated to a technician. It also provides very consistent objective results, no matter who is measuring, enabling me to detect disease earlier, and track improvements in corneal sensitivity if I'm doing some sort of intervention.
“If you had to choose one device for dry eye disease, what would you pick?”
If I had to narrow things down to one in-office device for inflammation, it would be intense pulsed light (IPL)—with an asterisk. I've been doing IPL for the last seven years; and it’s hard to imagine not having it. It’s so beneficial for reducing lid margin inflammation; and improving meibomian gland function, tear film stability, and—most importantly—patient symptoms. 80–90% of patients that go through an IPL course will have symptomatic improvement.
Saying that, you cannot discount gland obstruction. You can do a manual expression after IPL, but it won’t be nearly as good as doing something with a heating element to it. This is why there’s an asterisk—you need something to help with lid margin disease and meibomian gland obstruction. Historically, LipiFlow and TearCare have been my ‘go-to’s. I have experience with iLux and am increasingly using Tixel. LLLT is not exactly in that same category, but does provide a good way to do gland expression.
We tend to fail when we look at IPL as a silver bullet; it should be part of a comprehensive treatment regimen.
Dr. Dierker’s full responses to these and additional questions can be found in the VOD of the session.
