Cory J. Lappin, OD, MS, FAAO, founder of the Dry Eye Center of Ohio, leads a roundtable with Jessilin Quint, OD, MS, MBA, FAAO, Andrew Zagelbaum, OD, and Mandy Rights, OD, on how they build an over-the-counter (OTC) foundation for dry eye disease (DED) before adding prescription therapy.
Dr. Quint practices at Smart Eye Care, a multi-location Maine practice with a dedicated dry eye center; Dr. Zagelbaum practices at the Dry Eye Center of Arizona, a dry eye–only practice in Phoenix; and Dr. Rights owns BRIGHT Eyes, a dry eye center and eye spa in Boone, North Carolina, with an integrative ocular nutrition focus.
How dry eye specialists build the OTC foundation
All four panelists start with the same three components—a nutraceutical, a specific preservative-free artificial tear, and lid hygiene—whether a patient is new to treatment or years into it. Prescription and procedural therapies are layered on top of that base, not substituted for it.
The nutraceutical: inside the LCD trial
Drs. Rights and Quint both use Blink NutriTears (Bausch + Lomb), a single daily softgel capsule, partly because it avoids the dose- and quality-specific counseling that omega-3 recommendations require. Its lutein, zeaxanthin, curcumin, and vitamin D3 (LCD) blend was evaluated by Gioia et al in a prospective, randomized, double-blind, placebo-controlled trial at four Florida centers.1
Adults aged 18 to 65 with diagnosed DED and Ocular Surface Disease Index (OSDI) scores of 12 to 40 took one capsule (lutein 20mg, zeaxanthin isomers 4mg, curcuminoids 200mg, vitamin D3 600 IU) or a soybean oil placebo each morning for 56 days; 155 participants were randomized and 116 completed the study.1
Compared with placebo, the LCD group showed:1
- Significantly better Schirmer scores and OSDI scores at day 56 (co-primary endpoints; P<.001 for both)
- Separation from placebo on total OSDI and Standard Patient Evaluation of Eye Dryness (SPEED) scores by day 14, sustained through day 56
- Significant improvement in tear breakup time (TBUT), tear osmolarity, and corneal and conjunctival staining by day 56 (P<.001)
- A 67.39% (right eye) and 61.36% (left eye) reduction in matrix metalloproteinase-9 positivity from baseline, vs. increases of 6.67% and 8.70% with placebo
- No difference in artificial tear use
Dr. Lappin will sometimes pair the supplement with omega-3s, viewing the LCD formula as a complementary anti-inflammatory and antioxidant; that combination has not been studied in a controlled trial.
Download the cheat sheet here!
Dry Eye Toolkit: OTC Tears and Nutraceuticals
Use this cheat sheet to quickly compare active ingredients in OTC artificial tears for dry eye and key nutraceuticals that can aid in managing ocular surface disease.
Choosing the artificial tear
When it comes to choosing an artificial tear, Dr. Quint decides between lipid-based and aqueous formulations based on meibomian gland dysfunction, gland truncation, screen use, and contact lens wear. She prioritizes OTC drops with clinical data behind their claims.
Blink Triple Care pairs hyaluronate with a lipid nanoemulsion.2 In a multicenter, double-masked randomized trial (158 randomized; 130 per protocol), the original preserved formulation was noninferior to a commercially available non-lipid tear on overall ocular comfort at day 30, with no difference in blurred vision.3 A preservative-free multidose version of the same formula launched in the US in June 2026.2
As for the financial aspect, Dr. Rights reframes price for patients as cost per use rather than cost per bottle: a drop that provides 8 or more hours of relief is a better value than a cheaper drop used every 2 hours.
The panel also dispenses recommended products in-office. Dr. Quint calls the retail shelf "the eye drop aisle of doom," where patients default to the cheapest or best-packaged option.
Product vetting carries safety weight: a 2022 to 2023 multistate outbreak of extensively drug-resistant Pseudomonas aeruginosa traced to contaminated artificial tears involved 81 patients in 18 states, and 4 of the 18 patients with eye infections underwent enucleation.4
Lid hygiene and heat
DEWS III lists lid wipes, anti-Demodex therapies, and blepharoexfoliation among lid hygiene options.5 For warm compresses, adherence declines as application frequency and duration increase; a review of studies published from 2004 to 2023 recommends a moist-heat eye mask, microwavable or self-heating, for at least 10 minutes per eye.6
Adherence determines whether treatment failed
Dr. Rights opens with meibography or lid margin imaging, which she finds convinces patients their symptoms have a treatable cause. Patients leave with every recommended product and a handout that lays out morning, midday, and evening routines. Her team calls at 2 weeks—the point at which most patients decide whether a regimen is working—and she reassesses measurements at 6 to 8 weeks.
Dr. Quint also checks in at 2 weeks for OTC regimens and extends the interval for prescription agents with a slower onset, treating interim visits as coaching sessions. Dr. Zagelbaum schedules the first follow-up at 2 months, repeats baseline testing, and judges progress by whether objective measures are moving in the right direction; patients are told they can call sooner. That interval accommodates the evidence that signs lag symptoms by months with regular tear use.7
When to escalate beyond the foundation
Dr. Quint usually pairs OTC care with an additional therapy for symptomatic patients and reserves OTC-only plans for milder or minimally symptomatic disease. Specific findings change her plan: systemic inflammation, contact lens wear, rosacea (intense pulsed light), and end-of-day symptoms in screen users (perfluorohexyloctane). Dr. Zagelbaum ties additions to exam findings—low meibum quality, low tear meniscus, rapid breakup, or lash debris—rather than trial and error.
Within the Bausch + Lomb prescription portfolio, perfluorohexyloctane (MIEBO) targets evaporation; a meta-analysis of five randomized trials found significant improvement in total corneal fluorescein staining at 8 weeks (standardized mean difference, −0.53).8 Lifitegrast (XIIDRA) belongs to the T-cell immunomodulator class that DEWS III includes for inflammatory drivers.5 Neither replaces the OTC base.
The panelists describe their thresholds shifting with experience. Dr. Quint now uses adjunct therapy in most patients because she has seen patients lose years on mild regimens alone. Dr. Zagelbaum, a 2023 graduate, learned to rein in reflexive prescribing early in his career. Dr. Rights credits DEWS III with changing her escalation sequence. Dr. Lappin stacks therapies but will reset patients who arrive with a bag of partially effective products and rebuild from the basics.
Key takeaways
- TFOS DEWS III replaced the DEWS II severity-based ladder with management matched to each patient's etiological drivers, organizing therapy into 10 categories that include tear supplementation, lid hygiene, and nutritional therapy.5
- Regular artificial tear use—about 4 times daily—improves DED symptoms within 1 month, while signs generally take several months to improve; patients with no benefit after a month should be moved to alternative management.7
- Across randomized trials, combination formulations outperform single-ingredient tears, polyethylene glycol–based tears outperform carboxymethylcellulose- and hydroxypropyl methylcellulose–based tears, and patients with evaporative DED benefit from liposomal formulations.7
- Benzalkonium chloride, used in approximately 70% of ophthalmic formulations, damages corneal and conjunctival epithelium, with effects documented after as little as 7 days of exposure.9
- DEWS III concludes that the overall evidence favors oral omega-3 supplementation in DED, although the optimal source, dose, and omega-3:omega-6 ratio remain undefined.5
- In a 2026 cross-sectional study of patients undergoing DED treatment, roughly one-third said they might not adhere because of cost (33.4%), treatment duration (32.7%), or regimen complexity (34.1%).10
- A once-daily lutein, zeaxanthin, curcumin, and vitamin D3 supplement met both primary endpoints in an 8-week, placebo-controlled US trial (detailed above).1
In closing
The panel's shared position is that no patient is too mild or too advanced for an OTC foundation of a nutraceutical, a preservative-free tear, and lid hygiene. Product selection should follow the evidence and the patient's drivers, and sourcing matters as much as formulation. Before labeling a regimen a failure, confirm adherence, then escalate to prescription or procedural therapy for the drivers the foundation cannot reach.
For more information on driver-based management, check out: What Optometrists Need to Know About TFOS DEWS III with Cheat Sheet and Hastening Symptom Relief in Dry Eye Disease.
This article was written by Mariel Mohns, MS, based on the recorded conversation between Drs. Lappin, Quint, Rights, and Zagelbaum.
