There is no one-size-fits-all approach when it comes to treating dry eye disease (DED), just as no set of dry eyes are the same. While signs and patient-reported symptoms may be similar, the etiology or the reason behind these symptoms may drastically vary from patient to patient.
Accordingly, the appropriate treatment will vary based on their medical history, risk factors, and disease stage. Luckily in today’s landscape, the treatment options at our disposal allow us to develop a plan tailored specifically to meet each patient’s needs.
Factors that determine DED treatment
Over the last several years, increased interest and research into DED has led to a better understanding of how dry eye syndrome impacts all aspects of eyecare—from surgical outcomes to spectacle remakes to contact lens intolerance and discontinuation. This has led to the development of a variety of novel treatment options in the dry eye space.
Treatments either aim to ease the symptoms of DED, target the root cause, or help with both. Due to the often multifactorial nature of DED,1 a patient may benefit from one or more of these treatment options simultaneously or at different times during their journey.
A successful treatment selection is determined by three important factors:
- Medical History: Understanding and documenting a patient’s ocular history, risk factors, prior treatments (failed and successful), and medications (topical and systemic) as well as the severity and timing of their symptoms, will help inform the treatment selection and can prevent us from recommending treatments the patient may have already tried.
- Testing: A robust workup with the necessary testing, such as meibography, ocular surface photos, tear meniscus height, tear break-up time (TBUT), lipid layer thickness, blink analysis, corneal sensitivity testing, and corneal vital dye staining, will help determine the different factors contributing to the patient’s symptoms and inform an accurate diagnosis.
- Examination: The exam and expert assessment of the clinician, combined with the patient’s history and testing results, will ultimately determine the best treatment plan.
Available treatments for dry eye disease
Treatments available today range from prescribed topical therapeutics to over-the-counter and at-home therapies, and in-office procedures. In this section we will explore some of the most widely available treatments today and who could potentially benefit from them.
Common treatment options for DED include:
- Prescription topical therapeutics
- Punctal plugs
- Thermal pulsation and gland expression
- Intense pulsed light (IPL)
- Radiofrequency (RF)
- Eyelid hygiene
- Over-the-counter treatments
Prescription topical therapeutics
Prescription eye drops are often a first line of defense as they can target inflammation on the ocular surface and associated structures, increase tear production, or stabilize the tear film, which can ease the symptoms and the perceived discomfort associated with DED.
Lifitegrast and cyclosporine target inflammation,2,3,4 while some prescription treatments, like cyclosporine and varenicline nasal spray, also increase tear production, which can be especially helpful in patients with aqueous deficient dry eye.5,6,7
In contrast, a patient diagnosed with evaporative dry eye may see little to no improvement from increased aqueous production if it’s been determined they produce an adequate amount of tears, but their tears evaporate too quickly from the ocular surface. In cases such as these, tear film stabilizing drops like perfluorohexyloctane can help reduce the evaporation of tears and improve patients’ signs and symptoms.8,9,10
Often covered by insurance, prescription topical therapeutics are a good option to jumpstart a patient who has not received treatment prior. In addition, they can often be used in combination with other treatments that may take longer or require multiple sessions before results can be expected.
Punctal plugs
Punctal plugs are tiny devices that can be implanted in a patient’s tear ducts in an effort to artificially increase the amount of moisture on the eye at any given time. Punctal plugs can be temporary or permanent and be used as a standalone treatment or in combination with other treatments.
While the restricted drainage that punctal plugs provide can help increase the amount of moisture present on the eye in patients diagnosed with aqueous deficient dry eye, indicated by a low Schrimer’s score, it may also exacerbate symptoms like epiphora in patients with adequate tear production.
Additionally, if a patient has uncontrolled inflammation, punctal plugs may worsen their symptoms as tears containing proinflammatory factors are held on the surface for longer periods of time.11
Also, while the added moisture may temporarily provide relief, it may also mask the symptoms and underlying causes still present in other forms of DED. Therefore, a patient’s entire ocular surface status needs to be carefully evaluated before punctal plugs are used.
Thermal pulsation and gland expression
With the prevalence of evaporative DED due to meibomian gland dysfunction (MGD), in-office thermal pulsation and meibomian gland expression procedures have allowed us to provide patients with the benefits of warm compresses in a controlled and effective manner. These treatments aim to safely apply heat to the eyelids and meibomian glands to first liquify (or soften) the meibum, and then evacuate it, allowing for healthy oils to be produced and secreted.12
LipiFlow, Systane iLux, and TearCare are the most widely available thermal-based gland expression treatments today. While they differ in heat delivery and expression methods, patients diagnosed with evaporative dry eye disease and MGD could potentially benefit from any one of these systems.13
Things to consider:
Thermal pulsation and gland expression success will vary from patient to patient and often hinges on the severity of the condition. Combined with gland expressibility and observed meibum quality, meibography is an essential tool that can help us manage patient expectations and the likelihood of these treatments being successful by directly assessing gland structure, such as the health of the glands and the degree of gland loss.
Intense pulsed light (IPL)
Initially US Food and Drug Administration (FDA)-approved for the cosmetic treatment of rosacea, IPL has also been used successfully in the treatment of DED.
IPL is thought to improve the signs and symptoms of dry eye by:14-18
- Reducing inflammation
- Improving meibomian gland structure and function
- Destroying proinflammatory telangiectatic blood vessels typically associated with ocular rosacea
- Reducing bacterial load on and around the eyelids
- Promoting collagen production in patients diagnosed with dry eye and MGD
Although IPL is widely used in the treatment of dry eye, Lumenis’ light treatment is the only IPL technology currently FDA-approved specifically for the management of dry eye and MGD.19
Things to consider:
IPL often requires multiple sessions (at least four, typically) spaced about 4 weeks apart, over a period of several months for optimal effect and duration. In addition, it is limited in its application to patients with specific skin types due to the risk of pigmentation changes in patients with darker skin tones.
Radiofrequency (RF)
Radiofrequency devices have been used in the management of dry eye as a way to deliver thermal-based energy via the use of radio waves.20-22 The depth of heat delivery can be altered based upon the frequency of the radio waves, allowing for more precise targeting of tissues such as the meibomian glands and the skin around the eyelids.21,22
Manual gland expression is typically performed after treatment with RF, making it an excellent treatment option for patients with MGD.22 Additionally, RF increases collagen production, which can improve the tone of the skin around the eyes, and can be used on patients of all skin complexions.20-23
Things to consider:
The two most commonly used forms of RF utilized for dry eye treatment are monopolar and bipolar RF, each of which requires different patient setups and considerations.
Additionally, treatment in patients with implanted medical devices, such as pacemakers, is typically contraindicated due to the potential for the radio waves to interfere with the device’s function. Therefore, it is crucial for you to familiarize yourself with the specifics of any RF device you may be working with.
Eyelid hygiene
Eyelid hygiene is an often overlooked factor that can play an important role in a patient's symptoms. Accumulation of excess oils, bacteria, and devitalized skin cells on the lid margins and lashes can significantly contribute to patient-reported symptoms of discomfort.24
Furthermore, lid hygiene can improve and prolong the efficacy of all other treatments. This is particularly important in patients with MGD, bacterial blepharitis, or demodicosis (Demodex blepharitis).25
Hypochlorous acid acid, tea tree oil, and okra-based cleansers are commonly used in maintaining ocular surface hygiene. While eyelid hygiene has traditionally included lid scrubs, wipes, or baby shampoo (although the use of baby shampoo should be avoided due to potential disruption of the tear film),26 there are also novel in-office treatment options that provide a more thorough and effective cleaning.
NuLids PRO is a minimally invasive, in-office eyelid hygiene procedure that targets debris on the lid margins and lashes on patients with blepharitis and MGD. Additionally, NuLids offers an at-home treatment for those patients who are more serious about their approach to treatment. BlephEx and ZEST are other commonly used lid cleaning procedures as well.
A newer hygiene-related device is Rinsada. Rinsida uses a lid retractor attached to a syringe to rinse the ocular surface with a high-pressure saline rinse by hooking under the eyelids and jetting water into the conjunctival fornices. This helps remove any trapped debris and flush away proinflammatory factors present on the ocular surface.27
Over-the-counter treatments and closing thoughts
In addition to the treatments above, lifestyle changes, dietary changes, supplements, and OTC therapies like artificial tears, warm compresses, sleeping masks, and moisture chamber eyewear can be used to customize a unique treatment plan that meets our patients’ needs.
Patient education, patient selection, and expectation management will all determine the success of each patient’s treatment plan. As technicians and patient advocates, we are in a position to counsel our patients on treatment selection, explain why specific treatments were recommended, provide coverage and cost information, and, ultimately, improve patient compliance and ensure each patient is receiving optimal care.
