Devin Pinaroc, FNP-C

Takeaways

• Conservative measures can be very effective when used in combination and strict adherence is practiced.
• Artificial tears are the mainstay treatment in Dry Eye Disease (DED), available in many different preparations, and should be initially tried 4-6 times a day. 
• Prescription medications, procedures, and devices treat severe disease when conservative therapies fail, but should be managed by an ophthalmologist/optometrist. 

 

Dry eye disease (DED) is a condition of the ocular surface characterized by tear film instability due to reduction of tear production and/or increased evaporative loss from any dysfunction of the lacrimal functional unit (Shtein, 2021). Symptoms include conjunctival injection, ocular burning, photophobia, visual disturbances and tend to eb and flow depending on associated factors (ie: seasonal allergies, increased screen time, contact lens) (Shtein, 2021). Even mild disease can affect vision and make daily tasks, like driving or reading, more difficult, affecting quality of life. Treatments target evaporation of the tear film on the surface of the eye and optimization of meibomian gland production to promote underlying ocular moisture (Messmer, 2015). 

 

Conservative Therapies 

There are many simple interventions that relieve symptoms, but efficacy relies heavily on patient adherence (O’Neil et al., 2019). Re-evaluation of treatment/care should follow 2-4 months of compliance to a combination of supportive therapies. 

Artificial tears are the mainstay treatment in any severity of DED, and several preparations are available over the counter. Although no RCT data compares efficacy, avoiding preservatives, especially benzalkonium chloride, is recommended to avoid ocular inflammatory response (Messmer, 2015). Initial dosing of artificial tears is 4-6 times a day for 1-2 months.  If treatment failure occurs, adding or switching to higher viscosity gel/ointment preparation can be more effective, but do cause temporary blurry vision (Shtein, 2021). 

Warm compresses over the eyes maintain secretions and patency of the meibomian glands. Eye compresses able to be microwaved are sold over the counter. Ten to fifteen minutes of warm compress therapy before bed, in combination with application of an artificial tear gel, can be very soothing. 

Environmental strategies such as avoidance of heating and air conditioning or room humidification reduce evaporation from the ocular surface. Frequent blinking is helpful in upkeeping the tear film (Shtein, 2021). Blinking decreases with attentive tasks like in computer use, so setting reminders to take frequent breaks can reduce evaporation of tears.  

Moisture Chambers create physical barriers around the eye to decrease exposure from the environment and maintain humidity around the eye (Shtein, 2021). These can be worn daily or only during times of exacerbation. 

 

Severe Disease Treatments

During the last decade, research into DED has increased as well as dry eye treatments available after conservative measures fail or for severe dry eye. An emerging, but not (yet) FDA approved, eye drop showed efficacy in using eye-platelet rich plasma and growth factors to address surface evaporation and promote ocular surface health. In-office procedures like meibomian gland probing, address meibomian gland health and output through mechanical energy or heat. A range of devices have been developed to offer alternative therapies to people with dry eyes. For example, the intranasal tear neurostimulator is a relatively new device that targets natural tear production through the nasolacrimal reflex pathway (O’Neil et al., 2019).

These medications and alternative therapies should be managed by an eye specialist (Messmer, 2015). The time to refer is patient dependent and should involve a discussion regarding cost, goals versus expectations of care, worsening or severity of symptoms, and continued compliance to conservative measures.  

 

Want to know more…

AAO – What Is Dry Eye?

Dry Eye Disease: Prevalence, Assessment, and Management

Update on the association between dry eye disease and meibomian gland dysfunction

 

References

Messmer E. M. (2015). The pathophysiology, diagnosis, and treatment of dry eye disease. Deutsches Arzteblatt international, 112(5), 71–82. https://doi.org/10.3238/arztebl.2015.0071

O’Neil, E. C., Henderson, M., Massaro-Giordano, M., & Bunya, V. Y. (2019). Advances in dry eye disease treatment. Current opinion in ophthalmology, 30(3), 166–178. https://doi.org/10.1097/ICU.0000000000000569

Shtein, R. M. (2021, April). Dry eye disease. UpToDate. https://www.uptodate.com/contents/dry-eye-disease?search=dry+eyes&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H6