There are remarkable tools for the diagnosis and management of dry eye currently clinically available to help those patients suffering from ocular surface disease. As such, it can at times be overwhelming to select appropriate treatment options for patients. As the number of treatment options have increased, so have our choices to help our patients. As such, we have needed to place priorities on two large overarching strategies:
- Provide Relief Improving the functionality of those structures that are critical to a healthy ocular surface will certainly help in providing relief. But, just as we may utilize agents to provide relief in other ocular conditions, such as acetaminophen or scheduled narcotics for pain relief while treating the inflammation with topical corticosteroids for anterior uveitis, we utilize a similar process to help our dry eye patients.
Individuals who have dry eye disease will present with a number of symptoms, including dry, burning, tired, and irritated eyes. They may also present with visual symptoms, such as blurry and fluctuating vision. Providing relief typically involves utilizing artificial tears to supplement the tears that are not being produced. Lipid-based tears are frequently utilized when lipid deficiency is present. Additionally, increasing the viscosity of drops to gels and ointments also provides additional relief for those who have more severe disease. You may consider hydroxypropyl cellulose ophthalmic inserts as sustained relief-providing agents that slowly dissolve on the ocular surface over a 24-hour time period.
- Improve Function Two components are involved in improving the function of a dry eye patient:
Mechanical This involves mechanically improving those structures that may be limiting successful tear production and balance on the ocular surface. In the absence of appropriately functioning meibomian glands, this includes exfoliating the lid margin (debridement) and thermal treatment. In the presence of anterior blepharitis, it includes cleaning the lid margin with eyelid hygiene and in-office lid cleaning procedures. In the absence of inflammation and the presence of insufficient tear production, attempts to retain tears on the ocular surface include punctal occlusion.
Chemical This involves chemically optimizing the ocular surface. In the presence of anterior blepharitis, it often includes some type of lid hygiene through commercially available preparations. Topical pharmaceutical options that are known to decrease inflammation include corticosteroids (to be used for short periods of time), cyclosporine, and lifitegrast. Oral options to help chemically optimize the tear film include doxycycline and ocular nutrition such as the appropriate balance of omega-3s and omega-6s in addition to other naturally occurring anti-inflammatory agents known to decrease inflammation on the surface of the eye.
In our quest to understand this condition, much of the research has led to remarkable tools to help us manage these individuals. It can potentially be a daunting task to prioritize treatment options for patients with the vast array of options available. Through prioritizing treatment with a global view of providing patients relief and improving function, we realize that we can set the stage for a more formally organized treatment strategy for our patients. Mentally categorizing this treatment strategy provides clinicians not only a structural foundation for protocol creation, but also helps more easily communicate this complex condition and the treatment options to patients in a more meaningful way. If overcomplicating dry eye treatments is the new norm, we don’t want to be normal. CLS