What's the biggest mistake doctors make when treating dry eye?
Dr. Dierker: If we rely only on patient symptoms and always chase them to make decisions about what's working or what we need to do, that is going to fail quite often. I think about treating disease and identifying etiologic drivers. I do a standardized symptom assessment.
And then I do a very methodical exam, including meibomian gland diagnostic expression, looking for other lid abnormalities, assessing the ocular surface with vital dyes, and then trying to understand which disease I am treating.
And then based on what the patient's telling me and what I see, I will talk through that with the patient and determine the treatment.
Other things I think about are a shotgun approach/over complication of a treatment regimen, where maybe you have a patient who comes in, and you try to do three or four things at once. Most of my patients can't do that. I try to do two or three treatments for a patient, but with some patients, I can only get them to do one thing.
Are we still thinking of dry eye primarily as a tear deficiency, as meibomian gland disease, or as both?
Dr. Dierker: I think clearly the shift has been towards more evaporative dry eye and mixed mechanism disease. And that is our modern understanding of how most patients end up with dry eye: there's an evaporative component. But basically, when evaporation exceeds total tear supply, you get desiccating stress on the ocular surface, osmolarity goes up, and you get in this dry eye cycle.
“The reality is, I would say that most dry eye is not really a tear problem; it's a gland problem. And that's how I look at that in my clinical practice.”
The interesting thing is that sometimes when a patient starts primarily aqueous-deficient, eventually, that patient's going to have meibomian gland dysfunction as well. It may be even more commonly seen in younger patients due to screen time and poor blinking. So in a referral clinic, I would say the most common subtype is actually mixed disease.
How do you diagnose ocular rosacea versus MGD?
Dr. Dierker: This is a very relevant question because it will determine how I manage that patient. Ocular rosacea, a dermatologic disease, is inflammatory in nature and may present with signs such as lid margin telangiectasia, conjunctival hyperemia, and corneal staining.
But specifically ocular rosacea, if you see anything beyond just very subtle lid margin telangiectasia, I call that ocular rosacea. And then, certainly, if you're seeing overt MGD, chalazia, facial rosacea, well, you know, this patient often not only has ocular rosacea, but probably has a Demodex issue as well. If it's just MGD, that's talking about obstruction only. So they can have poor gland secretion, poor gland quality, or poor oil quality, yet minimal lid inflammation.
Biggest unmet need in dry eye today?
Dr. Dierker: I think it would be great if we had a diagnostic test battery to help inform a treatment plan that is vetted and evidence-based. With this, our management will take a much more targeted approach for that individual based on their symptoms and diagnostic tests.
“Another unmet need is that is treatment for ocular surface pain and neuropathic pain”
There are some things in development, one of which is being fast-tracked and is something we hope to have within the next year or so.
Finally, I get frustrated when I see patients who come to me who have advanced ocular surface disease, and they have significant meibomian gland dropout and loss. So if we can have a treatment that truly restores and regenerates meibomian glands, I think that would be a game-changer. Hopefully, with better diagnostics, we can have a more targeted approach.
What do we do with patients on OXERVATE with pain?
Dr. Dierker: We know that patients receiving OXERVATE recombinant nerve growth factor for neurotrophic keratitis can experience pain. I've not had a patient who I've had to stop treatment because of pain. Typically, we can manage their other ocular surface issues and get them through that with basically education that this is a temporary phenomenon.
How do you try to convince patients to do things like IPL without insurance coverage?
Dr. Dierker: I'm not trying to sell or convince a patient to do anything. I'm trying to educate a patient. So if a patient comes in and they have symptomatic ocular surface disease, and I see that there's an ocular rosacea component and MGD component, and I think that they would benefit from IPL, I try to tell the MGD story, identify what symptoms are bothering that patient the most. I tie that into my clinical exam. I won't reserve that for a recalcitrant patient if I think that's the right initial approach.
One of the things that I've also done is create some images in our Google Chrome shortcuts where I can show them what IPL is or other therapies, such as low-level light therapy, TearCare, LipiFlow, and Tixel, the newest one, and I show them how it works and what we're trying to do and how it ties back to their symptoms.
I educate patients that insurance companies don't always agree with me, even when the device is FDA-cleared or FDA-approved. It may not be covered, but patients can use flex spending or HSA funds.
Make sure to watch the full video to get further insights into the current state of DED management in 2026!
