Dry eye disease (DED) is no longer an afterthought in the exam lane—it’s a core part of our diagnostic and therapeutic focus. Across the country, optometrists are seeing more patients of all ages and demographics presenting with symptoms of dry eye (see DED: The Big Picture),1-4 and it’s no coincidence.
Factors like increasing public awareness, a modern lifestyle, and a surge in treatment options have culminated in more patients not only talking about dry eye but actively seeking a solution.
The global prevalence of DED is estimated to be between 5 and 50%,1 affecting between 38 and 40 million people in the United States alone.5 Many individuals with DED, however, are not even on a therapeutic treatment—in the United States, only about 1.5 million individuals are treated for DED.5
Driving the rise in the prevalence of DED is a combination of longer life expectancy, increased screen time at all ages, environmental contributors, such as indoor heating and air conditioning and pollution, and increased awareness.6
Pinpointing prevalence: Patients prone to DED
The following three groups account for the patient populations I have found are most affected by DED in my clinical practice.
1. Those with aging eyes
As a referral-based dry eye specialist, I traditionally see more severe and chronic DED cases, often accompanied by meibomian gland dysfunction (MGD) and chronic blepharitis, cases that are usually in the Medicare-age population.
Common findings in this age group include:
- Reduced tear production
- Lid laxity
- Prolonged topical medication use
- Systemic conditions that are important risk factors for DED, such as autoimmune and connective tissue disorders like Sjögren syndrome, rheumatoid arthritis, and Graves disease, and metabolic conditions like diabetes and thyroid disease.
Large epidemiological studies have shown DED prevalence increases every 5 years after the age of 50.9-14 Interestingly, I’ve noted a surge in working-age individuals affected by chronic DED. These patients often spend long hours on screens and are motivated to seek treatment beyond over-the-counter (OTC) artificial tears.
To learn more about current artificial tears on the market, check out A Comparative List of Artificial Tears–with Download!
2. Females
I’ve also seen more female patients presenting with DED, particularly those who are peri- and postmenopausal. Patients in these groups are particularly at risk for dry eye as estrogen and androgen fluctuations affect the lacrimal and meibomian glands, altering tear composition and contributing to both evaporative and aqueous-deficient DED.15
Many of these patients have previously tried OTC lubricants with little to no improvement. I make sure to provide education explaining that dry eye is a disease and that effective therapy involves treating the root cause(s), such as inflammation, inadequate tear production, and/or MGD, rather than just treating the symptoms.
In addition, cosmetic use may influence ocular surface health.16-19 Some eyecare providers may provide a curated list of gentle, non-irritating makeup brands to patients if it’s a concern. Encouraging proper makeup removal and a switch in products may also help complement their overall DED management strategy.
3. Contact lens wearers
All too often, contact lens use is an underappreciated factor in DED until symptoms drive discontinuation. Studies have shown discomfort—not reduced vision—is the primary reason up to 64% of patients drop out of lens wear.20
Despite advances in contact lens materials and solutions and clear guidelines on contact lens wear schedules, the dropout rate has barely budged in several decades. If we want to reduce contact lens dropout, we must treat the underlying contributory risk factors like inflammation, MGD, and Demodex blepharitis.
Initiating the use of daily disposables or preservative-free contact lens solutions may help, but oftentimes these changes alone are not enough if a patient has unmanaged MGD, blepharitis, or inflammation.
Tailoring DED treatment
In all three at-risk populations, I believe in tailoring treatment plans to minimize complexity and specifically target the individual contributing factors for each patient.
A personalized treatment plan typically offers prescription treatments to increase tear production and decrease evaporation. I make sure to address other risk factors like lifestyle and any other contributing systemic medications, such as antihistamines, beta-blockers, and diuretics, that can worsen symptoms.
Additionally, counseling patients on basic changes to environmental risk factors, such as decreasing digital screen exposure time, more frequent blinking, monitoring hydration, and avoiding the use of overhead fans, may make an impact on their quality of life.
With the aging population specifically, compliance and simplifying the treatment regimen are paramount. Dexterity is often an issue, further complicating drop instillation and use. I choose more efficacious prescription drops, punctal occlusion with canalicular gel, and in-office treatments when necessary.
Collaborating with primary care physicians and other specialists like rheumatology can also help to reduce systemic dry eye risks by properly treating uncontrolled systemic and autoimmune diseases.
Treatments: Tried-and-true and new
Anti-inflammatory therapy is a cornerstone of DED management and has shown benefit in both aqueous-deficient and MGD / evaporative DED.
Since the approvals of cyclosporine ophthalmic emulsion 0.05% (Restasis, AbbVie), cyclosporine ophthalmic solution 0.09% (Cequa, Sun Ophthalmics), and lifitegrast ophthalmic solution 5% (Xiidra, Bausch + Lomb), another wave of FDA-approved DED therapies has further expanded the therapeutic landscape.
Vevye
We now have access to a cyclosporine that is the first and only formulation to receive approval for the treatment of both the signs and symptoms of DED. Cyclosporine ophthalmic solution 0.1% dissolved in a semifluorinated alkane (Vevye, Harrow) spreads evenly over the ocular surface.
It has been shown to produce both a longer residual time and an increased penetration of cyclosporine compared to older formulations.19 Patients report it is comfortable on instillation. In clinical trials, corneal healing was seen in as little as 15 days.20
Eysuvis and Flarex
Loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis, Alcon) and fluorometholone acetate 0.1% ophthalmic solution (Flarex, Harrow) may be appropriate choices for patients desiring rapid symptom relief and inflammation control.
The former is currently the only FDA-approved corticosteroid with an indication specifically for the short-term treatment of dry eye. As short-term ocular corticosteroids dosed four times daily for 2 weeks, they are an excellent option for DED flare-ups.
Recently approved DED therapies
Some newer DED treatments target pathways other than inflammation or offer an alternative to drops. For example, the semifluorinated alkane perfluorohexyloctane (Miebo, Bausch + Lomb),3,4 is theorized to restrict tear evaporation and mimic key functions of natural meibum.21
An intranasal spray, varenicline solution 0.03% (Tyrvaya, Viatris), uses neurostimulation to stimulate the lacrimal functional unit and help produce basal tears. It has been shown to increase Schirmer scores by more than 10mm in about 50% of patients.22-24
Additionally, acoltremon ophthalmic solution 0.003% (Tryptyr, Alcon), a topical agonist of transient receptor potential melastatin 8 (TRPM8) that increases tear production via stimulation of the pathway responsible for basal tear production, was approved by the FDA in late May.25,26
Pipeline DED therapies
There are also other medications in the pipeline, such as Reproxalap (AbbVie), a reactive aldehyde species modulator; the FDA recently accepted the resubmitted NDA with a PDUFA target date of December 16, 2025. Medications like this represent the next wave of DED treatments we’re likely to see in the coming years.
Key takeaways
If I had to offer my top five takeaways for identifying and treating DED, they would include the following:
- Be proactive. Ask every patient about dry eye symptoms, regardless of age or complaint.
- Dig deeper. Perform a thorough examination, including corneal NaFl staining, gland expression grading that involves evaluation of the quality and quantity of meibum, tear osmolarity testing, meibography, looking for collarettes by having patients look down, checking for incomplete lid closure, and inflammation testing.
- Tailor by population. All patients, but specifically older adults, female patients, and contact lens wearers each require customized education and treatment.
- Treat early. Prescription therapies can preserve function and reduce progression when started sooner.
- Stay informed. New therapies are emerging quickly. Staying current will help you offer patients the best treatment.
