Dry Eye Syndrome Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Treatments of dry eye syndrome include the following:

• Artificial tear substitutes
• Gel/ointments
• Moisture chamber spectacles
• Anti-inflammatory agents

  • Topical cyclosporine A
  • Topical corticosteroids
  • Topical/systemic omega-3 fatty acids: Omega-3 fatty acids inhibit the synthesis of these lipid mediators and block the production of IL-1 and TNF-alpha.
• Topical/systemic tetracyclines
• Punctal plugs

  • Absorbable - Made of collagen or polymers. The occlusion duration ranges from 7-180 days. The plugs dissolve by themselves or may be removed by saline irrigation.
  • Nonabsorbable - Made of silicone. Two main categories of silicone plugs are available for dry eye: punctum plugs and intracanalicular plugs.
  • Cylindrical Smartplug® - Made of a thermosensitive, hydrophobic acrylic polymer that changes from a rigid solid to a soft, cohesive gel when its temperature changes from room temperature to body temperature.
• Secretagogues - Diquafosol (INS365, DE-089) – P2Y2 receptor agonist
• Autologous/umbilical cord serum
• Contact lenses

  • Silicone rubber lenses
  • Gas permeable scleral-bearing hard contact lenses with or without fenestration
  • Highly oxygen-permeable lenses (overnight wear)
• Systemic immunosuppressives
• Surgery

  • Amniotic membrane transplantation
  • Lid surgery
  • Tarsorrhaphy
  • Mucous membrane/salivary gland transplant

Class Summary

Act as humectants in the eye. The ideal artificial lubricant should be preservative-free, contain potassium, bicarbonate, and other electrolytes, and have a polymeric system to increase its retention time.

Artificial tears (hydroxypropyl methylcellulose (HPMC), carboxyl methylcellulose (CMC), polyvinyl alcohol (PVA), glycerine artificial tears)

Used to increase lubrication of the eye.

White petrolatum, castor oil, hydroxypropyl-guar, mineral oil, hydroxy methylcellulose, carboxyl methylcellulose, and similar lubricants (Duolube, HypoTears, Refresh Endura, Systane, Refresh PM, Tears Naturale PM, GenTeal Gel, Tears Again Night&Day)

Serves as lubricant and emollient.

Class Summary

Reduce symptoms resulting from moderate-to-severe dry eye syndromes.

Hydroxypropyl cellulose (Lacrisert)

Acts to stabilize and thicken precorneal tear film and to prolong tear film breakup time, which occurs with dry eye states.

Class Summary

Lower mucous viscosity by digesting mucoproteins. Use when mucous discharge or plaques are present.

10% N-acetylcysteine drops (Mucomyst)

This mucolytic agent can be used successfully in patients with corneal filaments secondary to extreme keratitis sicca.

Class Summary

Empiric antimicrobial therapy must be comprehensive, covering all likely pathogens in the context of the clinical setting.

Tetracycline analogues, such as doxycycline and minocycline, have been shown to be effective on meibomian gland dysfunction. The effects of these antibiotics occur via 4 ways: (1) Antibacterial effects by causing a reduction in the bacterial load on the eyelid; (2) antiangiogenic effects; (3) anti-inflammatory effects resulting from a decrease in activity of collagenase, phospholipase A2, and several matrix metalloproteinases, and from a decrease in the production of IL-1 and TNF-alpha; and (4) inhibition of lipase production, which decreases production of diglycerides and free fatty acid (FFA) in meibomian secretions. (FFA can destabilize the tear film and can cause inflammation.)

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Minocycline (Dynacin, Minocin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma.

Class Summary

Cyclosporine may act as a partial immunomodulator. The exact mechanism of action is not known.

A randomized, double-masked, vehicle-controlled clinical study evaluated the efficacy and safety of two different concentrations of cyclosporine (1% and 0.05%) in aqueous solution compared to vehicle. At day 21 (noted as early in the trial), statistically significant improvement in 4 symptoms and 3 ocular signs were observed when cyclosporine 1% was administered, and equivalent improvement in 3 symptoms and 3 ocular signs was observed when cyclosporine 0.5% was used.^[10]

Cyclosporine ophthalmic (Restasis, Neoral, Sandimmune)

Used to relieve dry eyes caused by suppressed tear production secondary to ocular inflammation, and also meibomian gland dysfunction.

Class Summary

Are unpreserved, are nonantigenic by nature, and contain growth factors, fibronectin, immunoglobulins, and vitamins at similar (or higher) concentrations than in tears. Used for severe dry eye with punctate epithelial defects and corneal damage to promote reepithelialization.

Autologous serum (20%) and umbilical cord serum (20%) eye drops

Serum eye drops can be used successfully in patients refractory to other forms of treatment.

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. Inflammation is the key component of the pathogenesis of dry eye. Topical corticosteroid agents can be used to reduce the inflammation.

Loteprednol etabonate (Alrex, Lotemax)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Topical ester steroid drop with decreased risk of glaucoma. Available in 0.2% and 0.5% drops.

Fluorometholone (Flarex, Fluor-Op, FML, FML Forte)

Inhibits edema, fibrin deposition, capillary dilation and phagocytic migration of acute inflammatory response and capillary proliferation, collagen deposition, and scar formation. Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses capillary permeability. Believed to act by the induction of phospholipase A-2 inhibitory proteins.

Used topically, it can elevate IOP and cause steroid-response glaucoma. In clinical studies of documented steroid responders, fluorometholone demonstrated a significantly longer average time to produce a rise in IOP than dexamethasone phosphate. In a small percentage of individuals, a significant rise in IOP occurred within 1 wk. The ultimate magnitude of the rise was equivalent.

Class Summary

Certain dietary supplements may have beneficial effects.

Omega 3 fatty acids (Coromega, Longs Fish Oil, Max Epa, Omega-3, Salmon Oil, Superepa)

These agents may have anti-inflammatory effects. May inhibit leukocyte function.