Comprehensive Patient Guide For the Treatment of Dry Eyes

Welcome to our Comprehensive Patient Guide For The Treatment Of Dry Eyes. 

There so are many different treatment options for dry eyes. It can be confusing and frustrating for patients to know what’s right for them. 

Treatment decisions should always be made in consultation with your eye doctor. However, this “Comprehensive Patient Guide” will provide a strong foundation for which treatment options might be right for you.

Overview

Our medical team developed this guide after reviewing the guidelines of medical societies around the world, and combining it with first-hand experience from doctors who treat dry eyes every day. 

It’s organized in the following sections:

  • Principles of Treatment
  • Step 1: Where to Begin
  • Step 2: Universal At-Home Treatments
  • Step 3: Specific Treatments For Underlying Causes
  • Step 4: Prescription Medications
  • Step 5: Advanced Therapies

Principles of Treatment

We developed this guideline with several principles in mind:

  1. Effectiveness
  2. Safety
  3. Convenience
  4. Cost

Ideally, the next treatment any patient tries should be effective, safe, convenient, and low cost. Artificial tears is a great example of a treatment that ranks high in all of these areas. 

On the other hand, surgical options may be very effective, but they come with increased risks, are not as convenient as over-the-counter medications, and can be significantly more expensive.

Step-wise Approach

Our Guideline is laid out in a stepwise approach from the easy & convenient things that every dry eye patient should be doing, and progressing towards treatment options for more severe disease. 

We encourage everyone to consider starting at Step 1. Even if you’ve had dry eye for years, there may be some ideas that you skipped that might make all the difference for you. 

Let’s get started!

Step 1: Where to Begin 

Diagnostic Evaluation / See An Eye Doctor

Seeing a doctor early in your management of dry eye symptoms is important. Your doctor will help identify several key individual factors:

  • Type of dry eye syndrome
  • Risk factors 
  • Identifying the underlying cause

Part of your evaluation will help determine the type of dry eye syndrome you have. The main types are: 

  1. Aqueous deficient
  2. Evaporative
  3. Mixed

The vast majority of patients have at least some component of evaporative dry eye. Pure aqueous deficiency-type dry eye is much less common. However, treatment may differ in these situations, so it is important to have a diagnosis before getting too far along and frustrated that you’re not getting results. 

Risk Factor Modification

Patient: “Doctor, it hurts with I do this.”

Doctor: “Stop doing that.”

This isn’t always so easy. Some risk factors are harder to identify, and some are harder to change. However, it’s important to do a thorough review of your lifestyle, habits, and environment. There are often easy ways to change these risk factors that can result in big improvements.

Examples of risk factors you may be able to change:

  • Exposure to wind / fans / air currents
  • Occupational exposures
  • Computer screen time / habits
  • Smoking
  • Alcohol
  • Medications

We consider these “risk factors” because they don’t necessarily cause dry eye in every patient, but in some cases they do. 

Identifying Underlying Causes

There can be many underlying causes of dry eye syndrome. Work with your doctor to identify these, and then tailor treatment to your specific condition. 

The list of underlying causes if long. Here are some of the more common causes:

Step 2: Universal At-Home Treatments

There are at-home treatments that are available to virtually everyone, so we call them “Universal At-Home Treatments”. These are typically helpful in almost all patients. That doesn’t mean you have to use them all. For some patients warm compress are the key. Other patients may find that lid scrubs work best. 

The list of Universal At-Home Treatments:

  • Artificial tears
  • Warm Compresses
  • Lid Hygiene
  • Lubricating Ointment
  • Moisture Chamber Devices

Artificial Tears 

Virtually everyone with dry eyes should be using artificial tears. They are the fastest, safe & effective way to get relief from dry eye symptoms.

Most patients should start with a preserved artificial tear. That’s because for most patients preservatives are a good thing.

Preservatives keep your eyedrops from growing harmful bacteria and other infectious pathogens. They allow more drops to be stored in an individual bottle for a longer time before going bad.

However, a minority of patients can be allergic to certain preservatives. If you develop a red and itchy eye after using a drop, you may be allergic. Consult with your doctor and consider switching to a preservative-free artificial tear. 

Preservative-free tears will cost more, and they have to be stored differently, typically in small single-use vials. However, they will avoid any allergy to the preservatives. 

Warm Compresses

Warm compresses can help open the oil glands that are located along the eyelid margin.

These glands produce an oil that is necessary for making your natural tears function properly. These oils stabilize the tear film, and keep them from evaporating.

When these oil glands become blocked, your tears won’t function properly and your eyes can become dry.

Warm compresses are helpful for many patients. The heat helps to melt the thickened oils that clog the glands, and gentle pressure helps to push the melted thickened secretions out of the glands to restore normal flow.

A good starting point for warm compress therapy is 3 times per day for 3 minutes at a time.

Lid Hygiene

Debris and thickened, crusty oils can build up on the eyelid margin blocking the oil glands. By cleaning this area regularly, this build-up is cleared, allowing the oil glands to function properly.

There are a variety of commercial products available, such as Ocusoft.

Lubricating Ointment

Artificial tear ointments can help heal, protect, and lubricate the surface of the eye. 

While thick ointments are often the most soothing, they also can cause blurry vision. As a result, most patients prefer to use these at bedtime while asleep, and not during the day.

Common brands of ointments include Refresh P.M. and Genteal. 

Moisture Chamber Devices

Moisture chambers are devices like goggles that prevent dryness from fans, air conditioning, or sleep apnea devices from drying out the surface of the eyes.

These may be particularly suitable for patients who are unable to sleep with their eyes closed. This may be due to a variety of medical conditions or injuries to the eyelids. 

Step 3: Specific Treatments For Underlying Causes

Certain types of dry eye syndromes from different underlying causes have specific treatments for them. 

If the “Universal At-Home Treatments” in Step 2 don’t work, it’s usually time to discuss with your doctor if there are more specific and targeted treatments for your type of dry eye syndrome.

  • Meibomian gland dysfunction → Office-Based Thermal Compression
  • Rosacea blepharitis → Intense Pulsed Light (IPL) Therapy
  • Demodex → Tea Tree Oil Treatments
  • Aqueous Deficiency → Punctal occlusion
  • Allergy → Anti-allergy medication

Step 4: Prescription Medications

There are many different prescription medications that can be helpful in treating dry eye syndromes. 

We include these in Step 4, because for many of these treatments, they can be expensive, needed for the long-term, and, therefore, not as convenient as the treatments in Steps 1-3. 

However, every patient is different. If an underlying cause can be identified that can be treated with prescription medication, then that may be a more appropriate intervention earlier in the Steps.

For example, if a patient has a flare-up of allergic blepharitis, then a short-term anti-inflammatory or prescription anti-histamine eye drop may be the best-targeted treatment, to begin with before doing weeks of warm compresses while still being exposed to the allergen. 

Prescription drugs to manage dry eye disease:

  • Corticosteroids (example: loteprednol etabonate 0.5%)
  • Cyclosporine (Cequa, Restasis)
  • Lifitegrast (Xiidra)
  • Oral macrolide or tetracycline antibiotics

Step 5: Advanced Therapies

These “Advanced Therapies” require special order placement or a procedure performed by a doctor. They can be extremely effective in even the most severe cases. 

There is certainly no “one-size-fits-all” recommendation when we are at this point. At this level, you should be seeing a specialist who is comfortable and experienced with these options. 

Amniotic Membrane Grafts

Amniotic membrane grafts are rich in growth factors and other biologically active substances that promote healing. In a short procedure, a thin layer of amniotic membrane is placed on the surface of the eye, typically over the cornea. The membrane acts as a physical barrier, protecting the cornea from further damage, and also helps to reduce inflammation and promote the growth of new cells. The membrane eventually degrades and is naturally absorbed by the body, but the benefits of the treatment can last for several months.

In some patients who have poorly healing corneal epithelial defects resulting in dry eye syndromes, these grafts can be very helpful.

Scleral Contact Lenses

Scleral contact lenses are designed to vault over the entire cornea and rest on the sclera (the white of the eye), creating a tear-filled chamber between the lens and the cornea. 

This helps to keep the cornea hydrated and protected from environmental irritants and reduces symptoms such as eye dryness, itching, and burning. Scleral contact lenses can also help to stabilize the tear film and provide a smooth, even surface for the eyelid to glide over, reducing friction and further irritation. 

Unlike traditional soft contact lenses, which can rub against and dry out the cornea, scleral lenses vault over the cornea and keep it well-lubricated. They can be especially useful for individuals with severe dry eye, or for those who have tried other treatments without success.

Autologous Serum Tears

Autologous serum tears are a type of artificial tears that are created from a person's own blood serum. 

They contain growth factors, cytokines, and other substances that promote healing and reduce inflammation, which can help to improve the health of the ocular surface and reduce the symptoms of dry eye.

Since the serum used to create the tears is obtained from the person's own blood, it is well-tolerated and free from substances that can cause inflammation or irritation. 

The procedure for creating autologous serum tears involves drawing a small sample of blood from the person, which is then processed to extract the serum. The serum is mixed with a preservative-free saline solution to create a tear-like solution that can be used as eye drops.

These have to be specially ordered, and can not be filled at typical commercial pharmacies. 

Surgical Options

There are also surgical options for dry eyes. Typically, these are reserved for late in treatment. 

Permanent Punctal Occlusion

Permanent punctal occlusion may be performed. This is typically done in patients who have had success with other types of punctual plugs, but they keep falling our requiring replacement. In this procedure, the punctum is scarred shut. Of course, the downside of this is that it is not easily reversible.

Eyelid surgeries 

There are a variety of eyelid surgeries that can be performed to help dry eye symptoms. For example, in some patients who are unable to blink from a facial nerve injury, a weight can be placed in the upper eyelid to help it close. This helps protect the cornea from exposure and may help alleviate dry eye symptoms. 

Another procedure called a “tarsorrhaphy” involves stitching the eyelids together, either partially or all the way. This is reserved for very severe cases. For example, some patients with facial nerve injuries are unable to blink at all in one eye. This puts them at a lifelong risk for exposure and infection. These patients may also have other injuries that prevent the eye from seeing well. In a blind eye that is chronically painful from exposure, it may be the best option to suture the eyelids closed to protect it and keep the patient comfortable. Sometimes this may be a temporary measure, such as in a patient who experienced trauma, and while they are recovering and in a coma, the eyelids can be temporarily closed to protect it while a neurologic recovery is hoped for. Again, these are often the most severe conditions in which other neurologic factors may play a role. 

Summary

Thank you for reading our Comprehensive Patient Guide For The Treatment Of Dry Eyes. We hope you learned some things that will serve as a foundation for discussion with your eye doctor to help improve your dry eye symptoms.