- Dry eye disease is chronic but treatable!
- The basic principles of dry eye treatment are education, implementation and consistency.
- A good treatment plan should address your eye health, while taking into consideration your physical and emotional wellbeing.
Artificial tears, cyclosporine, eyelid hygiene, lifestyle modifications, nutrition, procedures
Taking the first step
Dry eye disease (DED) is also known as dry eye syndrome, keratoconjunctivitis sicca and ocular surface disease.The typical DED symptoms are burning sensation, red eyes, blurry vision, grittiness, eye irritation, foreign body sensation, dryness, watery eyes, and pain.
An individual with DED can spend several months self-treating before seeing a specialist. This means trying countless over-the-counter (OTC) eye drops, warm compresses, gels, ointments and oral supplements, all the while suffering from symptoms of dry eyes. Not only is this physically and emotionally frustrating, it can also cost hundreds to thousands of dollars. OTC treatments can certainly help, but only if they are tailored to your specific needs, used consistently, and fit within the context of your overall health and lifestyle.
In this article, we provide an overview of DED treatment options. We want you to grasp the core concepts of why these treatments are recommended and how they fit with your eye care, and with your overall health and wellbeing.
The basics of dry eye treatment
The most important concept to realize about DED is that it is chronic, but treatable.1 We know this is difficult to hear, but we want to be upfront and truthful with you. There is no magic cure for DED. Just like diabetes and high blood pressure, once you have it, you have it for life. That said, DED, like other chronic conditions, is treatable. By consistently sticking with a good treatment plan, you can control your DED, and not let it get in the way of your life.
A good way to think of dry eye treatment is going back to the structure we discussed in the causes of DED. Namely, aqueous deficient (not making enough tears), evaporative (tears evaporate too quickly), nutritional (your diet) and lifestyle (occupation and the environment).2 We believe that a personalized treatment plan should address all of these things, and that what is good for your eyes should also be good for your body.
Artificial tears and dry eye treatment
Irrespective of which type of DED you have, using lubricating eye drops, such as artificial tears, is important to replenish your tear film and supplement your natural tears.3 Your tear film is important to protect the cornea, make your eyes feel comfortable and keep your vision clear. There are over 50 different types of over-the-counter (OTC) artificial tears on the market, and it can be very confusing identifying the one that works best for you.4
Artificial tears come in two varieties: those that contain preservatives and those that are preservative free. The most common preservative is called benzalkonium chloride (BAK). While preservatives make the artificial tears last longer on the shelf, they can have adverse effects on the surface of the eye, and can actually worsen DED in the long run.
As the name implies, preservative-free artificial tears (PFAT) do not contain preservatives, and therefore are gentler on the surface of the eye. However, PFAT should be handled with care, and typically come in small vials, which should be discarded after each use to prevent contamination. Recently, two companies have created bottles that can dispense PFAT without contamination for up to 90 days from opening.
Artificial tears can have many ingredients, and they address different aspects of the tear film. Your tear film contains three layers: mucin (sticky stuff), aqueous (water), and lipid (fat). The mucin layer sticks to the cornea, the aqueous layer is the water, and the lipid layer protects the other layers and seals in the lubrication. Artificial tears try to supplement the aqueous or lipid layers.
Artificial tears typically contain demulcents, which are aqueous supplements that provide lubrication and increase viscosity (thickness). These prolong the time the artificial tear stays in your tear film.5 They are listed as the “active ingredients” on the artificial tear packaging. Some examples include polyvinyl alcohol, polyethylene glycol, carboxymethylcellulose, propylene glycol, glycerin, dextran, sodium hyaluronate (hyaluronic acid) and many others.
Some artificial tears can also contain emollients, which are oil or fat-based agents that can protect tissue and seal in lubrication. Just as the lipid layer protects the other layers in your tear film, emollients can protect and prevent the evaporation of tears. These are typically located in the “inactive ingredients” section on the packaging. Typical emollients include lanolin, paraffin, mineral oil, phospholipids, flaxseed oil, petrolatum and many others.
Similar to artificial tears, there are several eye gels and eye ointments, which are typically reserved for nighttime use since they blur your vision. Gels and ointments contain similar ingredients to artificial tears, with more emphasis on emollients to increase viscosity and provide lubrication overnight while you sleep.
Eyelid hygiene: Warm compress + eyelid cleaning
While it may not be obvious, your eyelids play a crucial role in eye function, and in maintaining your tear film. Everytime you blink, you replenish the tear film which covers your cornea. Your eyelids contain meibomian glands, which are oil glands that help form the lipid layer of your tear film. Your eyelids are so important that when they malfunction, you inevitably get dry eyes. So having a good eyelid hygiene routine is foundational to DED treatment.
A good eyelid hygiene regimen contains a warm compress and an eyelash cleanser. In addition to being relaxing to the eyes and eyelids, a warm compress can supercharge your meibomian glands, making them function better.6 When your meibomian glands are warmed, they release lipids (fat), making your tear film stronger. You can make a warm compress at home or purchase a premade warm compress mask.
An eyelash cleanser helps clear away any debris, crusting or flaking that builds up on your eyelashes.7 We typically see this when meibomian glands malfunction, or when you have inflammation of the eyelids (blepharitis), or an infection from Demodex. You can use baby shampoo on a washcloth to clean your eyelashes, or buy premade eyelid wipes or eyelid sprays. The wipes will typically contain similar ingredients to the artificial tears, with the addition of tea tree oil, coconut oil, aloe vera, and other vitamins and minerals. The eyelid sprays may also contain hypochlorous acid, which may be helpful against Demodex infection.
The role of nutrition in dry eye treatment
Nutrition is perhaps the most overlooked part of DED treatment. It all starts with eating a healthy diet, rich in omega-3 fatty acids, antioxidants, vitamins and minerals, and drinking lots of water. Not only is this beneficial for your eyes, but it also enhances your overall health and wellbeing.8
One of the biomarkers we use to detect DED is tear osmolarity, which is an indirect indicator of how much aqueous (water) is in your tears. The higher the tear osmolarity, the lower the aqueous (water) in your tears. DED is typically associated with high tear osmolarity. Drinking water and staying hydrated may help bring more aqueous to your tears, lower their osmolarity and improve your tear film. Not to mention, your hydration makes everything else function better in your body.
Omega-3 fatty acids may also be beneficial in DED. Omega-3 fatty acids come in two forms: short chain and long chain. You want the long chain ones that contain eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are present in fish (tuna, salmon, trout and sardines), or in algal oil (derived from algae as a non-fish option). It may also be helpful to supplement your diet with Omega-3 fish oil capsules, but be mindful of the Omega-3 dose (typically 2000mg or more), and the EPA-to-DHA ratio (typically 2:1, such as, 1000mg EPA to 500mg DHA).
Inflammation plays an important role in DED pathology, and therefore eating foods with an antioxidant, anti-inflammatory profile may be beneficial.9 These include beta-carotene, which is a precursor for Vitamin A (fruit and vegetables), coenzyme Q10 (fish and whole grains), zinc and copper (fish, meat, legumes, mushrooms, kale, nuts and whole grains), vitamin E (green vegetables, nuts, seeds, and fortified cereals), vitamin C (fruits, juices and vegetables), vitamin B6 (chickpeas, non-citrus fruits, sweet potatoes, salmon and tuna), vitamin B12 (fortified cereals, dairy products, meat and fish) and vitamin D (eggs, fish, mushrooms and fortified cereals). Selenium (meat, fish and cereals), lactoferrin (milk, but best to supplement) and curcumin (turmeric) also have anti-inflammatory properties and may be helpful in DED treatment. You should certainly try to eat a balanced diet with the above nutrients, but there are several supplements available to help augment your diet.
We deeply care about nutrition because its benefits extend well beyond just your eyes. We will do a more thorough exploration in later articles of each of the nutrients important in DED treatment.
Lifestyle changes to improve dry eye treatment
In addition to nutrition, the second most overlooked part of DED treatment is lifestyle. Your occupation and environment can have a significant impact on your DED.10 Many of us spend hours looking at computer and mobile screens. When we do this, we strain our eyes and do not blink, which predisposes to developing dry eye symptoms or worsening DED. Taking a few minute break from looking at a screen may be helpful in giving your eyes a rest. Other times when your blinking decreases is during focused activities, such as driving, watching TV, playing video games (including games on the phone), reading and writing.
The key environmental risk factors to be aware of are high winds, low humidity, extreme temperatures, high UV index (very sunny), allergens, pollution and tobacco smoke.11 These triggers cause your tears to evaporate rapidly, and may even lead to inflammation directly on the cornea. Do not forget that these environmental triggers can also exist in your home or car. For example, high winds in the environment have the same effect as sleeping under a fan or in front of air conditioning, or having the air in your car blowing in your face. All these can lead to rapid tear evaporation.
We know it’s difficult to critically look at your surroundings, especially since our lives are so busy and you’re always on the go. But being mindful of these environmental triggers can help you identify easy solutions that can drastically improve your DED. Some examples include using a humidifier or installing an air purifier, not sleeping under a fan or moving the car vents away from your face, and getting a head start on your treatment on low humidity days.
Medical management to optimize dry eye treatment
A variety of other eye conditions and general health issues can impact DED.12 For example, most prescription drops used in glaucoma can cause or worsen DED. This is mainly because most glaucoma drops contain benzalkonium chloride (BAK), a preservative that can be harmful to the surface of the eye. In fact, most common eye drops contain preservatives. You should certainly not stop treatment for existing eye problems, but it may be worthwhile having a discussion with your eye doctor (ophthalmologist or optometrist) to identify drops that do not cause or exacerbate DED.
Eye surgery is not gentle on the surface of your eyes. This is because we use antispetics before and after surgery that can be caustic to the corneal surface. Moreover, the post-operative drops typically contain preservatives. Refractive surgery, such as LASIK, is directly associated with DED. This is not to say that you should forgo any eye surgery. But it may be helpful having a discussion with your eye surgeon about your eye exam and about preventing DED after surgery.
Contact lens use is another condition to be aware of. Many individuals use weekly, biweekly or monthly contact lenses. Meaning that they discard the lenses one week, two weeks or one month after use, respectively. This requires what we call good contact lens hygiene: making sure you take the lenses out daily and clean them, do not sleep in them, do not swim or shower in them, and discard them as instructed. As you can imagine, this is difficult to do, and many individuals often misuse their contact lenses, leading to DED, or worse, corneal scratches and infections. Daily contact lenses may be a good option for people with DED since you discard them at the end of each day. Using artificial tears while wearing contact lenses may also be helpful.
Various medical conditions are associated with DED. Being aware of them may help you identify dry eye symptoms early, and start treatment promptly. Autoimmune conditions, such as Sjogren’s syndrome, rheumatoid arthritis or lupus, are important risk factors for DED. Thyroid problems can manifest with thyroid eye disease, which can lead to severe dry eyes in untreated cases. Poor nutritional status (diet with low vitamins A, B, C, D and E, and low omega-3 fatty acids) cancer, dermatitis, diabetes, high blood pressure, rosacea, and menopause (hormonal changes) are just a few of many medical problems that are associated with dry eyes.13
Certain oral medications may cause DED as a side-effect. These include antihistamines, beta-blockers (used in heart disease and high blood pressure), antidepressants, anti-anxiety medications, antipsychotics, isotretnoin, diuretics, estrogen therapy and chemotherapy. These medications can be life saving, and you should certainly not stop using them. But it may be helpful to have a discussion with your primary care physician about other options, or prophylactically start a DED treatment plan.
During the COVID-19 pandemic, wearing masks has become standard. When you wear a mask, you can create air flow from the mask directly to your eyes, which is similar to sleeping under a fan. There is actually a term for this, called “mask-associated dry eye disease.” Now, of course you should definitely wear a mask during the pandemic, but it may be helpful to use a good treatment plan to fend off any dry eye symptoms while wearing a mask.
Prescriptions for dry eye disease
In the last few years, pharmaceutical companies have made significant progress in developing new therapeutics for DED.14 But, prescription medications should be a supplement to, and not a replacement for, a good overall treatment plan.
Since we know inflammation plays a critical role in DED pathology, there are several anti-inflammatory medications in the market. These include cyclosporine (such as, Restasis and Cequa) and lifitegrast (Xiidra). These medications may also increase tear production from the lacrimal glands. There are approximately another 8-10 drugs that are in clinical trials now that either work directly on the eyes, or on the eyelids, addressing blepharitis and meibomian gland dysfunction. In severe cases, or during DED flare ups, we sometimes use a topical steroid drop to rapidly alleviate symptoms.
Prescription eye drops for DED can be a great option for some patients.15 However, there are two main issues. One, it is important to realize that prescriptions are not a magic cure, and that they work best when used alongside an overall treatment plan. Two, many insurance providers will not cover DED prescription medications without prior-authorizations, which can make it difficult to obtain coverage for some patients.
It’s important to not solely rely on prescription medications as the magic cure, but to create a treatment plan that encompasses artificial tears, eyelid hygiene, nutrition and lifestyle.
Procedures used in dry eye treatment
In-office procedures can be a good option if other treatments are not helping. The typical procedures include punctal plugs, where we put plugs into your tear ducts in the lower eyelids so more tears stay in the eyes. Procedures, such as, LipiFlow, intense pulsed light therapy, iLux, TearCare, BlephEx, Thermoflo and NuLids address your eyelids, and specifically the meibomian glands.16 In severe cases of DED, we may use a scleral contact lens or an amniotic membrane, which is derived from human placental tissue and are rich in growth factors.
While in-office procedures could be a good option, there are two issues with them. One, the lack of price predictability and transparency for these procedures is frustrating for patients. Many of these procedures are paid out-of-pocket by the patient, and prices can range from $500 to $1500 depending on where you are in the country.
Two, oftentimes these procedures are marketed as quick fixes, but typically you need the procedure done multiple times. Moreover, just like with prescriptions, in-office procedures work best when used alongside a good overall treatment plan.
Putting it all together
A typical treatment plan contains a mix of the above listed options to provide dry eye relief.17 Artificial tears 4-6 times a day, eyelid hygiene 1-2 times a day, often a gel or ointment at nighttime, maybe a daily supplement, and procedures and prescriptions if or when needed. Some specialists may even spend the time to discuss lifestyle modifications and other health conditions that may be impacting your DED.
We here at CorneaCare believe that each person experiences DED differently. You need a treatment plan that is specifically tailored to you, and it has to take into consideration your motivations, goals and lifestyle. A successful treatment plan should protect your eyes, fortify your health, and strengthen your mind.
Starting a DED treatment plan takes effort, but we promise that it gets easier over time as your treatment becomes a habit and part of your daily routine. We are here to help you along the way. To listen and encourage you when things are tough, to applaud you when you make progress and to champion you when you succeed in taking control of your DED.
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