Published in Ocular Surface

How I Decide Which DED Rx to Prescribe to My Patients

This is editorially independent content
9 min read

Welcome to Dry Eye Fireside Chat; this episode features Drs. Dierker and Johnston discussing patient selection pearls for dry eye disease (DED) treatments.

In this first installment of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, hosts Josh Johnston, OD, FAAO, to discuss his patient selection process for dry eye disease (DED) treatment.
Considering the broad range of FDA-approved pharmaceutical treatments available, such as Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceuticals), Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan, An AbbVie Company), Xiidra (lifitegrast ophthalmic solution 5%, Novartis), Tyrvaya (varenicline solution nasal spray 0.03mg, Viatris), and Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Alcon), Dr. Johnston provides pearls for determining which of these therapies to prescribe to specific dry eye patients.

The elements of a dry eye workup

As a large portion of Dr. Johnston’s patients are referred to his clinic for DED, the technicians are instructed to run these patients through an array of diagnostic tests, including tear film interferometry, meibography, matrix metalloproteinase 9 (MMP-9) qualitative analysis, and osmolarity testing. Subsequently, this data is collected and then analyzed by Dr. Johnston, and he then performs a comprehensive dry eye exam.
As DED is multifactorial, many dry eye patients are on a continuum where they experience multiple types of dry eye, as well as potentially other concomitant ocular surface disease (OSD) or systemic diseases that contribute to their symptoms. Based on his clinical experience, Dr. Johnston noted that most dry eye patients have some level of meibomian gland dysfunction (MGD), anterior blepharitis from the collection of biofilm on the lash margin, inflammation, and suppressed aqueous tear production.
At his clinic, a holistic dry eye exam involves the following:
  • Looking at the patient’s lids for Demodex blepharitis
  • Looking at the lid margins for blepharitis and lid biofilm
  • Pressing on the lids to assess the quality and quantity of the expressed meibum
  • Performing a lid seal test to check for incomplete lid seal
  • Assessing fluorescein corneal staining patterns and measuring tear breakup time
For dry eye patients who come in for follow-up exams, he prefers to shorten the testing to osmolarity and fluorescein staining. He added that at this point in time, as his practice is now a mature dry eye clinic, he has moved away from diagnostic quizzes and questionnaires (though they are helpful) to focus more on diagnostic testing during intake.

Identifying which patients are good candidates for prescription DED therapies

When it comes to managing DED, the primary goals are to rehabilitate the corneal surface and improve the quality of the tear film. As such, there are three FDA-approved eye drops that Dr. Johnston tends to prescribe for his dry eye patients.
Generally, for patients that present to Dr. Johnston’s clinic with staining and inflammation, he prescribes Cequa. If patients do not respond well to cyclosporine, Xiidra can be a beneficial alternative due to its lifitegrast-based formulation. Further, for patients who cannot tolerate the higher concentration of cyclosporine in Cequa, Restasis can be useful as a substitute treatment option due to its lower concentration.
Dr. Johnston encouraged eyecare practitioners (ECPs) who treat dry eye patients to decide which pharmaceutical treatment to prescribe on a case-by-case basis, using the patient’s signs and symptoms, patient medical history, diagnostic testing results, and success with previous treatments as navigation guides. For example, typically, for patients with more severe symptoms, staining, and hyperosmolarity, Dr. Johnston would recommend a combination therapy of Cequa coupled with a corticosteroid to reduce inflammation.

On the other hand, patients with light staining and mild symptoms might be prescribed Restasis.

Dr. Johnston added that even for patients who don’t exhibit corneal staining but do report symptoms, he still tends to start them with a pharmaceutical treatment because the staining indicates that there is existing damage to the cornea. Essentially, earlier intervention helps to possibly prevent DED progression. In his professional medical opinion, Dr. Johnston mentioned that in terms of tolerability and efficacy, patients tend to respond well to cyclosporine leading him to gravitate towards Cequa, as its higher concentration could aid in providing slightly faster symptom alleviation.

Patient selection pearls for DED treatment

Similarly, Tyrvaya is an additional therapeutic approach for patients who have self-reported that other therapies failed, as it treats dry eye through chemical neurostimulation. This nasal spray might increase goblet cell degranulation, releasing mucin, meibum release from the meibomian glands, and increase natural aqueous tear production. So Tyrvaya is a nice treatment option to use by targeting all three layers of the tear film. Dr. Johnston usually prescribes Tyrvaya as an adjunct therapy, though he often uses it as a stand-alone or primary treatment for patients.
Occasionally, patients prefer to only be prescribed Tyrvaya as they want to avoid using eye drops. For patients who experience dry eye flares and are not interested in maintaining a chronic therapy, Dr. Johnston prescribes Eysuvis, as it is a well-tolerated, FDA-approved steroid for short-term intervention. A large subset of his patients are older and experience more severe DED symptoms, so Dr. Johnston also prescribes Eysuvis for these patients who are already on long-term treatments but require additional support during inflammatory flare-ups.
Additionally, he tends to start patients with more severe signs and symptoms of DED on Eysuvis with another eye drop because this combination therapy can improve symptoms faster than monotherapy. Lastly, for patients who experience episodic dry eye, Eysuvis could act as a rescue drop to manage short-term dry eye flares.

Patient communication and DED therapeutic approaches

When Dr. Johnston recommends a prescription treatment, he will then customize the discussion based on their exam findings along with the patient’s medical history. At the end of the exam, he provides the patient with a summary of the exam, featuring a “treatment sheet,” which is a cheat sheet that provides further details on the therapies the patient is being prescribed.
If the patient has MGD, Dr. Johnston mentioned adding an at-home therapy, such as a Bruder eye mask. Depending on the case presentation, he might offer in-office lid treatments, such as LipiFlow or TearCare.
He outlines to the patient that the treatment process is a journey, so instead of prescribing the patient four treatments at the beginning, potentially overwhelming them, he starts them on one or two therapies that control inflammation, rehabilitate the cornea, and increase natural tear production. Dr. Johnston highlighted that setting clear expectations for patients around the timeline of symptom improvement is key.

Dr. Johnston’s general script for explaining DED and Cequa to a patient:

“Dry eye symptoms are caused by a variety of factors, so I’m recommending that you use a Bruder eye mask as a warm compress to address any obstruction in your eyelids. Also, I will be prescribing Cequa, an FDA-approved eye drop that you use twice a day, once in the morning and once at night, to increase your natural tear production and suppress inflammation.

While this is not a magic bullet or cure, it will start you on a journey to helping you feel better. This could help with symptoms as quickly as 4 weeks, or potentially sooner; at the latest, by the 2- or 3-month mark, you will likely start to feel better.

Ultimately, this is a marathon and not a sprint, so I will see you back in 6 weeks to evaluate the progress, and if you are not getting the improvement you want, we will add another therapy to help. If you are doing better, we will reduce or remove one of these therapies to simplify the treatment and make it more convenient.”

Patient education on how to administer Tyrvaya

For patients being prescribed Tyrvaya, Dr. Johnston explains that there is now an FDA-approved nasal spray available that helps increase natural tear production. Next, he demonstrates how to use the nasal spray with the patient by taking out the bottle and priming it for the patient while explaining in more detail the mechanism of action for Tyrvaya.
He added that Tyrvaya can be prescribed as a primary treatment; however, because it is not an eye drop, it’s especially important to slow down and go step-by-step with the patient to explain how to correctly use the medication.


It’s an exciting time for ECPs specializing in dry eye, as there are so many new treatments on the market and even more that are in development, with some coming to the market by the end of the year (i.e., MIEBO, VEVYE).
Using these clinical pearls, ECPs will be more prepared to appropriately formulate a treatment plan for their dry eye patients.
Damon Dierker, OD, FAAO
About Damon Dierker, OD, FAAO

Dr. Dierker is Director of Optometric Services at Eye Surgeons of Indiana, an adjunct faculty member at the Indiana University School of Optometry, and Immediate Past President of the Indiana Optometric Association. Dr. Dierker is the Co-Founder and Program Chair of Eyes On Dry Eye, the largest event for eyecare professionals in the industry. He has made significant contributions to raising awareness of dry eye and ocular surface disease in the eyecare community, including the development of Dry Eye Boot Camp and other content resources across dozens of publications.

Damon Dierker, OD, FAAO
Josh Johnston, OD, FAAO
About Josh Johnston, OD, FAAO

Dr. Josh Johnston is the Clinical Director at Georgia Eye Partners and an adjunct faculty member at Southern College of Optometry serving as the Residency Director at GEP. He founded Oculus Consulting Partners to help eye doctors and practices start and improve their dry eye practices offering consulting that blends technology and expertise to offer simpler, more efficient, and smarter consulting.

Josh Johnston, OD, FAAO
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