Published in Ocular Surface

It’s Time to Flip Your Dry Eye Protocol

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7 min read

Kick off 2024 by learning how to flip your dry eye disease (DED) protocol and adopt interventional approaches to effectively address the root causes of DED.

It’s Time to Flip Your Dry Eye Protocol
The most common approach to treating dry eye disease (DED) is still the same one I used when I started practicing 15 years ago—artificial tears, warm compresses, lid scrubs, and omega-3 supplements, sometimes with the addition of an immunomodulator drop twice a day.
That adds up to at least four to six times per day that patients are doing something to self-treat DED. Since in-office treatments, such as intense pulsed light (IPL) and various thermal therapies, became available, practitioners have typically used them as a second-line approach after at-home care didn’t work.
In fact, these in-office procedures were even categorized as “Stage 2” treatments by the 2017 Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) report.1 However, it’s past time to flip this DED protocol.

The changing DED treatment paradigm

Over the last 5 years, there’s been a shift among many of us who treat DED to take a more interventional approach to treatment. “Interventional DED treatment” emphasizes in-office therapies as first-line treatments rather than secondary options after patients spend time self-treating.
By initiating these treatments earlier in the protocol, we can reduce the burden of self-care for our patients and provide a real solution. With 60.5% of optometrists surveyed in the 2023 Dry Eye Report stating they plan to expand their practice’s ocular surface disease niche, it’s safe to say a majority of ODs might welcome the benefits of this model.2

Freer DED patients, better care

Traditional DED self-care can be a lot of work for patients. Using some combination of eye drops, hygiene, and compresses four to six times per day can be a significant burden. Consequently, compliance often suffers, making it even less likely patients will achieve the primarily palliative benefits of their at-home therapies.3
The idea behind an interventional approach to DED management is much like the current algorithm used for treating glaucoma. Glaucoma surgery used to be primarily recommended long after the use of topical medications was initiated, but as more effective, low-risk procedures became available, the protocol changed.
Now patients have laser therapies, such as selective laser trabeculoplasty (SLT), offered as first-line options, and more effective microinvasive glaucoma surgery (MIGS) procedures available earlier in the course of therapy, rather than relying on home-based care using drops that carry the same compliance problems.
Similarly, we’re shifting the emphasis on DED from largely palliative self-administered care to doctor-delivered treatments that better address the root causes of DED and provide significant, long-lasting effects.

Getting ahead of DED progression immediately

When patients come in and tell me how they’re suffering from DED—it’s affecting their work and other activities—I want them to start feeling a difference quickly. Yet, in my experience, it took months for my patients to see even modest effects with traditional therapies and prescriptions (and that’s without factoring in compliance).
Taking a more aggressive approach to treatment not only allows us to deliver significant, measurable improvement in DED, which we don’t always get with traditional therapies, but it also lets us start making inroads immediately.
I can see patients for an initial DED evaluation and treat them the same day in the office, jumpstarting therapy on the meibomian glands, inflammation, telangiectasia, and Demodex blepharitis.
In my experience, patients often experience positive effects after a few in-office treatments and continue to improve.

Embracing in-office DED treatments

A lot of new technologies for treating DED have emerged over the last 3 to 5 years, with the pillars being IPL and thermal pulsation devices. I use OptiLight IPL (Lumenis) to treat patients with moderate to severe MGD, inflammation, telangiectasia on the lid margin, and/or ocular rosacea.
OptiLight minimizes abnormal telangiectasia,4-6 improves the meibomian glands’ structure and function,7-8 and reduces inflammation.9-11 Patients have a series of four treatments spaced 2 to 4 weeks apart, and they usually tell me they feel the improvement when they come in for their third treatment.
If patients have a great deal of inspissated meibum, I first treat them with OptiLight and then use the thermal therapy TearCare (Sight Sciences). OptiLight comes first in my protocol because I like to quiet any inflammation before applying heat to the eyelids. Patients usually feel the effects of TearCare within 1 to 2 weeks.
Once we’ve treated the root causes of DED, such as MGD and underlying inflammation, patients often begin to see significant improvement in a few weeks. And, in my experience, they don’t need to do a lot of self-care. I might recommend traditional therapies as adjuncts when a specific case calls for it (for example, an artificial tear or immunomodulator for a post-menopausal patient with decreased tear production), but patients tend to have much greater freedom from home care.

Implementing an interventional approach

If you’re thinking of taking an interventional approach to DED treatment, it may just be a matter of doing in-office treatments earlier in your treatment paradigm.
If you need to purchase equipment, I recommend looking at the evidence supporting the different DED treatment devices available, such as OptiLight for IPL, as Lumenis IPL technology is FDA-approved for the management of MGD and DED.
Also, look at various heat therapies for DED, such as TearCare, LipiFlow (Johnson & Johnson Vision), MiBo Thermoflo (MiBo Medical Group), and Systane iLux2 (Alcon). To get the diagnostic information you need to track the effects of DED therapy, the must-haves are very affordable.
For instance, I recommend giving patients a questionnaire, expressing the meibomian glands, and doing staining. I also like to use meibography, a nice-to-have diagnostic that permits detailed evaluation of the meibomian glands.

Conclusion

I think you’ll find that an interventional approach to DED is very rewarding. By doing procedures that help patients improve clinically and reduce the emphasis on self-care, we’re shifting the burden of treatment from patients to the doctors, and that benefits all of us.
  1. Jones L, Downie L, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017 Jul;15(3):276-283. doi: 10.1016/j.jtos.2017.05.008
  2. Geller M, Fahmy A, Dierker D, et al. The 2023 Dry Eye Report. Eyes On Eyecare. Published Feb 27, 2023. https://eyesoneyecare.com/resources/2023-dry-eye-report/.
  3. Agarwal P, Craig JP, Rupenthal ID. Formulation Considerations for the Management of Dry Eye Disease. Pharmaceutics. 2021;13(2):207. Published 2021 Feb 3. doi:10.3390/pharmaceutics13020207
  4. Toyos R, Toyos M, Willcox J, et al. Evaluation of the safety and efficacy of intense pulsed light treatment with meibomian gland expression of the upper eyelids for dry eye disease. Photobiomodul Photomed Laser Surg. 2019;37(9):527-531. doi:10.1089/photob.2018.4599
  5. Papageorgiou P, Clayton W, Norwood S, et al. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. 2008;159(3):628–632.
  6. Kassir R, Kolluru A, Kassir M. Intense pulsed light for the treatment of rosacea and telangiectasias. J Cosmet Laser Ther. 2011;13(5):216-22.
  7. Dell SJ, Gaster RN, Barbarino SC, et al. Prospective evaluation of intense pulsed light and meibomian gland expression efficacy on relieving signs and symptoms of dry eye disease due to meibomian gland dysfunction. Clin Ophthalmol. 2017;11:817-827. doi:10.2147/OPTH.S130706
  8. Yin Y, Liu N, Gong L, et al. Changes in the meibomian gland after exposure to intense pulsed light in meibomian gland dysfunction (MGD) patients. Curr Eye Res. 2018;43(3):308-313. doi:10.1080/02713683.2017.1406525
  9. Dell SJ. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 2017;11:1167-1173.
  10. Gao YF, Liu RJ, Li YX, et al. Comparison of anti-inflammatory effects of intense pulsed light with tobramycin/dexamethasone plus warm compress on dry eye associated meibomian gland dysfunction. Int J Ophthalmol. 2019;12(11):1708-1713. doi:10.18240/ijo.2019.11.07
  11. Liu R, Rong B, Tu P, et al. Analysis of cytokine levels in tears and clinical correlations after intense pulsed light treating meibomian gland dysfunction. Am J Ophthalmol. 2017;183:81-90.
Nathan Lighthizer, OD, FAAO
About Nathan Lighthizer, OD, FAAO

Born and raised in Bismarck, ND, Nate Lighthizer, OD, FAAO, is a graduate of Pacific University College of Optometry. Upon graduation, he completed a residency in Family Practice Optometry with an emphasis in Ocular Disease through Northeastern State University Oklahoma College of Optometry. Dr. Lighthizer has since joined the faculty at the Oklahoma College of Optometry and serves as the Chief of Specialty Care Clinics and the Chief of Electrodiagnostics Clinic.

In 2014, he founded and now heads the Dry Eye Clinic at the College of Optometry. Also in 2014, he was named the Director of Continuing Education as well as the Assistant Dean for Clinical Care Services at the Oklahoma College of Optometry. He is a founding member, and currently serves as Vice President, of the Intrepid Eye Society which is a group of emerging thought leaders in optometry. He was named a member of PCON 250—a list of the top 250 optometrists in the country who practice progressively, provide innovative patient care, conduct optometric research or excel in academia and share what they have learned with other optometrists to advance the profession.

Dr. Lighthizer lectures nationally on numerous topics, most notably advanced ophthalmic procedures, electrodiagnostics, and ocular disease.

Nathan Lighthizer, OD, FAAO
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