Dry Eye Treatment Overview

We list below strategies that may be helpful in treating dry eyes. These strategies listed below are derived from a review of the published literature. Our intention is not to outline a protocol for dry eye treatment but rather give a description of all interventions that may have a beneficial effect. Your physician is the only one who can recommend the best treatment strategy for you based on your symptoms and eye examination findings.

Replenish the Tears

● In severe dry eyes tear osmolarity increases. The tear hyperomolarity has been shown to cause ocular surface disease. Although there are some who disagree, the use of moderately hypotonic artificial tears has been shown by others to promote ocular surface disease healing in severe dry eyes. Available hypotonic tears include: Thera Tears, Hypotears and Akwa Tears. (Br J Ophthalmol. 2002 Aug;86(8):879-84, Ophthalmologica. 2001 Mar-Apr;215(2):124-7)

● Bicarbonate containing artificial tears have also been shown to promote healing in severe dry eyes. Available bicarbonate containing tears include: Bion Tears, Murine Tears. (Arch Ophthalmol. 1995 Mar;113(3):371-8, Cornea. 1993 Mar;12(2):115-20)

● Prolonging the contact time of artificial tears on the cornea also helps. This can be achieved using a gelling agent such as HP-guar (Systane), or using a viscous eye drop (Celluvisc/Liquigel).(Curr Med Res Opin. 2005 Feb;21(2):255-60, Curr Eye Res. 2004 Jan;28(1):55-62)

● Non preserved drops are the best. However if preserved eyedrops are to be used, then newer preservatives like GenAqua are preferable to Benzalkonium chloride (BAC).

● Oil containing eyedrops (Refresh Endura, Soothe) may be added if meibomian gland dysfunction is present. These eyedrops will replenish the lipid layer or tear film. Warm compresses over closed eyelids for 5 minutes will also replenish the lipid layer.

● In severe dry eyes and unresponsive surface disease patients have significant visual impairment and disability. In such patients the use of autologus serum eye drops has been shown to help. . Natural human tears contain many growth factors, antibodies etc. Since these growth factors are present in serum, using serum eyedrops may provide the surface healing properties of natural tears. The major disadvantage of serum treatment is the requirement for blood donation. The active components of serum are stable for up to 6 months therefore bleeding and serum preparation are required two to three times a year. A standard method to prepare the serum eyedrops has been described. Blood banks may help you in preparing serum eyedrops.(Br J Ophthalmol. 2004 May;88(5):647-52, Graefes Arch Clin Exp Ophthalmol. 2005 Mar 9)

It is apparent that there is no single artificial tear eyedrop that provides all of the surface healing strategies (bicarbonate ions, hypotonicity, viscosity, non-preserved). Therefore perhaps it may be beneficial to use different eyedrops interchangeably or sequentially - i.e. a drop of Systane or Refresh liquigel followed 5 minutes later by a drop of Bion Tears (Murine Tears has the preservative BAC, therefore avoid it) followed 5 minutes later by a drop of Thera Tears or Thera Tears liquid gel (Hypo Tears and Akwa Tears has BAC, therefore avoid them). This cycle may be repeated every 2 to 4 hours. At night use a non-preserved ointment like Refresh PM ointment. Avoid Lacrilube as it has preservative (chlorbutanol).

● Avoid the use of redness relieving eyedrops (naphazoline or tetrahydrozoline eyedrops) such as Clear Eyes, Murine Plus and Visine and herbals such as witch hazel. Also avoid using Vaseline in the eye. Avoid aggressive washing of the eye with running water or saline.

Treat Eye Surface Inflammation (red irritated eye, sore eye, tearing)

Once dry eye has developed, inflammation becomes the key mechanism of ocular surface injury, as both the cause and consequence of cell damage. Inflammation may be initiated by dryness, hypertonicity of tears, microtrauma from eyelids during blinking, proinflammatory substances released by the lacrimal glands or eyelids, and a reduced supply of supportive factors from tears and corneal nerves. When it is present, inflammation is enhanced by cytokines secreted by damaged surface epithelial cells; and lymphocytes and leukocytes that leak out from dilated conjunctival blood vessels. Thus patients with severe dry eyes can become trapped in an increasing cycle of inflammation and ocular surface injury. Ocular surface inflammation reduces surface wettability and tear film stability. (Prog Retin Eye Res. 2004 Jul;23(4):449-74)

Available antiinflammatory treatments include cyclosporin A (Restasis) eyedrops and steroid eye drops (Alrex, Lotemax, FML or Vexol). It may require several weeks of Restasis treatment (one drop twice a day) to produce a clinical therapeutic effect and it may take up to 6 months for maximum improvement. Therefore, Restasis is not an appropriate drug for immediate relief of an uncomfortable irritated eye. Topical corticosteroids have a rapid onset of anti-inflammatory action. They may be used for the short-term (2 to 4 weeks). It is worth remembering here that long-term use of streoid eyedrops can cause a rise in eye pressure (perhaps even glaucoma) and development of a cataract. Therefore, Restasis, which is devoid of these steroid-related side effects, seems to be a reasonable choice for long-term anti-inflammatory effect.

Treat Eye Allergy (itching, mucus strands in the eye)

If present, eye allergy may be treated with eyedrops such as Patanol and Alrex. (Note: Systemic antihistaminics like Claritin and Benadryl will increase dry eye symptoms - Ann Allergy Asthma Immunol. 2004 Nov;93(5):460-4)

Preserve Tears

Blocking the nasolacrimal drainage by inserting punctal plugs will prevent the tears from being drained into the nose resulting in greater retention on the eye surface. Sleeping with the eye surface isolated from the environment using moisture chambers or swimming goggles may help to preserve the tears. PanOptx Windless Eyewear are sunglasses that are fashionable enough to be worn in public, yet retain the function of a moisture chamber.

Treat Meibomian Gland Dysfunction (MGD)

The superficial lipid layer of the tear film is derived from the meibomian glands which are embedded within the eyelids. The meibomian gland ducts open on the eyelid margin. The lipid layer serves to reduce evaporation of underlying aqueous in the open eye. Meibomian Gland Dysfunction (MGD) causes abnormalities in the secreted lipids and dry eye results from increased evaporation of tears. MGD is treated with warm compresses, eyelid scrubs and the use of oral tetracycline/doxycyline.

In order to replenish the lipid film, eyedrops that contain oil may be used. These include Refresh Endura (castor oil) and Soothe eyedrops (mineral oil).

Oral supplements & Dietary advice

● Maintain a good water intake. Avoid diuretics such as alcohol and caffeine.

● Recent research has shown that oral therapy with polyunsaturated fatty acids reduces ocular surface inflammation and improves dry eye symptoms (Cornea 2003;22:97-101). It does make sense to increase omega-3 fatty acid intake i.e. eat more fish, or take oral flaxseed oil supplement, if you wish. Thera Tears Nutrition & HydroEye are oral pills that provide these supplements.

Address Environmental issues

● Air currents increase tear evaporation, therefore avoid car air conditioning and heaters.

● Use a humidifier to increase humidity in your surroundings which in its most basic form consists of a dish containing water on a windowsill or radiator.

● Avoid dry eye due to computer vision syndrome. Keep the monitor below eye level in order to reduce the exposed area of the eye. When looking down, the upper eyelid partially covers the eye, thus reducing the exposed area of the eye. Switching to a laptop may make working in downgaze easier.

● Avoid smoke and dust. (Do not party too much in smoke filled bars/rooms).

● Use wraparound sunglasses or side shields when outside.

Treat eyelid issues that may impact the tear film

If present, treat conjunctivalchalsis, lower lid laxity, floppy eyelid syndrome, inadequate eyelid closure while sleeping, seborrheic blapharitis, ectropion, entropion, trichiasis and nasal mucosa/sinus inflammations.

Lifestyle issues

Dry eye disease has a negative impact on everyday life, particularly in daily activities. Adequate counseling may help. (Invest Ophthalmol Vis Sci. 2005 Jan;46(1):46-50)

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