February 26, 2018 | POSTED BY | Anterior Segment, Clinical Optometry, Clinical Pearls, Study Resources
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Dry eye is constantly in the news and the way we treat it is always changing. The publication of the 2017 Report of the TFOS International Dry Eye Workshop II (more commonly known as the TFOS DEWS II) provides evidence-based treatment and management of this multi-factorial condition from experts around the world. Here is a summary of the treatment outlined in the DEWS II.

Step 1:

  • Patient education: Talk to your patients about the condition, treatments, management, and prognosis.
  • Environmental modifications: Discuss modifiable factors such as facing fans and heaters away from the patient’s eyes.
  • Dietary modifications: Omega 3 fatty acids anti-inflammatory and may help to improve the function of the meibomian glands. Omega 3 (1,000 – 3,000 mg EPA + DHA per day) can be found in fish oil or flaxseed oil.
  • Modification/elimination of contributory systemic and topical medications: Remember, anti-histamines, anti-psychotics, anti-depressants, acne medications, hypertensive agents, pain relievers, chemotherapy medications, estrogen replacements, and contraceptives can cause or exacerbate dry eye.
  • Artificial tears: Check out our guide on prescribing artificial tears. Consider lipid based ATs if there is MGD.
  • Lid hygiene: Debris/scurf at the base of the eyelashes can clog the meibomian glands and cause irritation and inflammation. DEWS recommends against homemade scrubs especially with baby shampoo as it can exacerbate dryness. Additionally, patients should not be given permission to make their own homemade products as there is no control over the quality, quantity, and possible adverse reactions. Products available for purchase include lid wipes/scrubs, and hypochlorous sprays.
  • Hot compresses: Hot compresses are heat (40C/104F) placed on closed eyes for 10 to 15 minutes, twice a day (morning and evening). Hot compresses help the liquefy the oil in the meibomian glands and increase the oil layer of the tear film, also leading to improved tear quality and decreased evaporation. Commercially available products include microwavable eye masks with beads that retain heat for longer periods of time.

Step 2:

  • Preservative free artificial tears
  • Tea tree oil: Tea tree oil is toxic to Demodex. If Demodex is present on the eyelashes, wipes/lid scrubs with tea tree oil can be recommended for purchase.
  • Punctal plugs: Punctal plugs are inserted into the superior and/or inferior puncta to block tear drainage and allow the tears to stay on the eyes longer. These are used if the tear film is healthy and there is no inflammation. There are two main types of punctal plugs; semi-permanent ones are made of silicone, while dissolvable ones are made of collagen and eventually absorbed by the body. Dissolvable punctal plugs are often used prior to semi-permanent ones to determine treatment efficacy.
  • Moisture chamber goggles: These also work to conserve tears and may be worn at night.
  • LipiFlow: In office therapy using a machine that warms the oil in the meibomian glands and increases the oil component of the tear film. This helps to produce better quality tears that stay on the eyes longer.
  • Intense pulsed light therapy (IPL): IPL is a non-laser high intensity light that is applied to the skin to treat MGD. It is believed to heat up the meibum in meibomian glands and treat telangiectasia associated with rosacea.
  • Prescription medications: Anti-inflammatory topical medications such as Restasis and Xiidra can be prescribed to increase tear production and decrease symptoms, respectively. Antibiotics such as oral doxycycline and AzaSite (topical azithromycin) are used for their antibiotic and anti-inflammatory properties and can be prescribed for meibomian gland dysfunction and blepharitis. Topical steroids may be used for a limited period of time to decrease inflammation.

Step 3:

  • Autologous serum eye drops: These are eye drops made a patient’s own blood serum, which has bioactive agents that promote healing of the ocular surface. Disadvantages are that they are often expensive and not readily available.
  • Contact lenses: Sclerals may be used in more severe or recalcitrant cases of dry eye. Sclerals allow a layer of fluid between the cornea and the lid, like a liquid bandage protecting the cornea. Bandage contact lenses may also be considered.
  • Oral secretagogues: These are cholinergic agonists including pilocarpine and cevimeline which promote secretion and are prescribed for patients with Sjogren’s.

Step 4:

  • Amniotic membrane: Amniotic membranes (AM) are harvested from placentas. AMs treat severe ocular surface disease by promoting healing, decreasing inflammation, and having anti-microbial properties. There are two types of AMs. ProKera is cryopreserved and secured by a ring, and stored in a freezer until use. A numbing agent is applied and the AM is applied in a manner similar to applying a contact lens. The ring is removed in office after the AM has dissolved. AmbioDisk is dehydrated and is very thin. A numbing agent is applied, and the AM is applied to the cornea, ensuring that it is right side up. Saline is applied to rehydrate the AM, and then a bandage contact lens is placed on the eye. Patients may experience blurred vision and discomfort during the time of treatment.
  • Surgical approaches: These may include surgical punctal occlusion (which is permanent) and tarsorrhaphy which fuses the upper and lower lid margins.
  • Topical steroids may also be considered for longer duration.

Artificial Tears/Anti-inflammatory Drop Chart

AT - dry eye chart - ipad

Please note that the treatment depends on the underlying cause (aqueous deficient, evaporative, inflammatory, nutritional, or autoimmune). Check out Part 1 of this series which discusses the pathogenesis and types of dry eye!

Special thanks to our Senior Editor Jessica Chan for her help in writing this article!