eMedicine Specialties > Ophthalmology > Lacrimal System
Dry Eye Syndrome: Treatment & Medication
Updated: May 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The International Dry Eye WorkShop (DEWS) Subcommittee members reviewed the Delphi Panel (the Dry Eye Preferred Practice Patterns of the AmericanAcademy of Ophthalmology and the International Task Force Delphi Panel on Dry Eye) approach to the treatment of dry eye and modified it.1
Treatment recommendations are based on disease severity.
- Level 1
- Education and environmental/dietary modifications
- Elimination of offending systemic medications
- Preserved artificial tear substitutes, gels, and ointments
- Eyelid therapy
- Level 2 – If level 1 treatment is inadequate, add the following:
- Nonpreserved artificial tear substitutes
- Anti-inflammatory agents
- Topical corticosteroids
- Topical cyclosporine A
- Topical/systemic omega-3 fatty acids
- Tetracyclines (for meibomianitis, rosacea)
- Punctal plugs (after control of inflammation)
- Secretagogues
- Moisture chamber spectacles
- Level 3 - If level 2 treatment is inadequate, add the following:
- Autologous serum, umbilical cord serum
- Contact lenses
- Permanent punctal occlusion
- Level 4 – If level 3 treatment is inadequate, add the following:
- Systemic anti-inflammatory agents
- Surgery
- Lid surgery
- Tarsorrhaphy
- Mucous membrane grafting
- Salivary gland duct transposition
- Amniotic membrane transplantation
- See related CME at Topical Cyclosporine May Be Helpful for Dry Eye Disease.
Consultations
A rheumatologist can be consulted if a systemic collagen vascular disease is suspected.
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
Ophthalmic agents and lubricants
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.
Adult
1-2 gtt qd/qid (may use more if preservative-free)
Pediatric
Administer as in adults
None reported
Documented hypersensitivity to preservatives (eg, benzalkonium chloride)
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Avoid frequent dosing of preserved tears; if wearing contact lenses, use rewetting or lubricating drops specifically for contact lenses; discontinue with eye pain, redness, or visual changes
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.
Adult
Pull down lid of affected eye, and apply small amount (0.25 in) of ointment to inside of the lid from every hour to just at bedtime depending on severity
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use with contact lenses; discontinue use if eye pain, irritation, continued redness, or vision changes occur
Ocular inserts
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.
Adult
Insert 5 mg qd into inferior cul-de-sac beneath the base of the tarsus; some patients may require bid frequency
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperemia, photophobia, stickiness of eyelashes, ocular discomfort, or irritation may occur
Mucolytic agents
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.
Adult
1 gtt tid/qid
Pediatric
Administer as in adults
None reported
Do not use simultaneously with contact lenses
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in patients with a possible infectious ulcer or concomitantly with topical antibiotics
Antibiotics
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.
Adult
100 mg PO qd/bid if indicated for meibomian gland dysfunction
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
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.
Adult
100 mg PO qd for at least 3 mo if indicated for meibomian gland dysfunction/acne rosacea
Pediatric
<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupus-like syndromes may occur
Immunomodulators
Cyclosporine may act as a partial immunomodulator. The exact mechanism of action is not known.
Cyclosporine (Restasis, Neoral, Sandimmune)
Used to relieve dry eyes caused by suppressed tear production secondary to ocular inflammation, and also meibomian gland dysfunction.
Adult
Topical: Instill 1 gtt in each eye q12h
Oral: 1.25 mg/kg PO bid
Pediatric
<16 years: Not established
>16 years: Administer as in adults
When administering systemic dose carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; ocular infection; in systemic dose, contraindications include uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UVB radiation in psoriasis since it may increase risk of cancer
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Herpes keratitis; do not administer while wearing contact lenses; may cause ocular burning, conjunctival hyperemia, ocular discharge, excessive tearing, eye pain, foreign body sensation, pruritus, stinging, or blurred vision;
When administering systemic dose, evaluate renal and liver functions by measuring BUN, serum creatinine, serum bilirubin, and liver enzymes; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Only physicians experienced in immunosuppressive therapy should prescribe cyclosporine; manage patients in facilities equipped and staffed with adequate lab and supportive medical resources; may increase susceptibility to infection and development of neoplasia;
may administer Sandimmune with adrenal corticosteroids but not with other immunosuppressants
Autologous serum eye drops
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.
Adult
Instill 1 gtt in the affected eye(s) 8 times/d; discard bottle at end of day and open new bottle every day
Pediatric
<16 years: Not established
>16 years: Administer as in adults
None reported
Patients with blood-borne infectious diseases (eg, hepatitis B and C, HIV, syphilis); anemia
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
No major complications; isolated reports of scleral vasculitis/melting in patients with rheumatoid arthritis, immune complex deposition, and microbial keratitis; prepare under sterile conditions to avoid microbial contamination; freeze at +4°C (up to 1 mo) or -20°C (up to 3 mo)
Corticosteroids
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.
Adult
Instill 1-2 gtt qd/qid; shake vigorously before using
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with long-term use; long-term local steroid application may result in fungal infections of cornea; consider possibility of fungus invasion if corneal ulcerations persistent (perform fungal cultures when appropriate); monitor intraocular pressure if used for 10 days or longer (may be difficult in children and uncooperative patients)
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.
Adult
Ointment: Apply qd/qid
Solution: Instill 1-2 gtt qd/qid; shake vigorously before using
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; herpes simplex, keratitis, viral and fungal diseases of the ocular structure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with long-term use; long-term local steroid application may result in fungal infections of cornea; consider possibility of fungus invasion if corneal ulcerations persistent (perform fungal cultures when appropriate); prolonged use my result in elevated intraocular pressure or glaucoma (monitor intraocular pressure if used for 10 d or longer; may be difficult in children and uncooperative patients)
Dietary supplements
Certain dietary supplements may have beneficial effects.
Omega-3 fatty acid (Coromega, Longs Fish Oil, Max Epa, Omega-3, Salmon Oil, Superepa)
These agents may have anti-inflammatory effects. May inhibit leukocyte function.
Adult
0.3-0.5 g of daily EPA + DHA and 0.8-1.1 g of linolenic acid
Pediatric
Not established
May reduce effects of aspirin, vitamin supplements (especially containing vitamins A and/or D), blood thinners (eg, warfarin), antiplatelet drugs (eg, clopidogrel, ticlopidine), diabetes medicine (eg, glyburide, insulin), cyclosporine, etretinate, and other natural/herbal products
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in diabetes, certain hereditary conditions (eg, familial adenomatous polyposis), and hemodynamic problems
More on Dry Eye Syndrome |
| Overview: Dry Eye Syndrome |
| Differential Diagnoses & Workup: Dry Eye Syndrome |
 Treatment & Medication: Dry Eye Syndrome |
| Follow-up: Dry Eye Syndrome |
| References |
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References
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Further Reading
Keywords
dry eye syndrome, dry eye, dry eye disease, DES, keratoconjunctivitis sicca, KCS, Sjögren syndrome, SS, Sjögren syndrome associated keratoconjunctivitis sicca, non-Sjögren syndrome associated keratoconjunctivitis sicca, Sjögren syndrome associated KCS, non-Sjögren syndrome associated KCS, tear film disorder, decreased tear production, aqueous tear deficiency, ATD, deficient aqueous production, evaporative loss
